Question #
int64 1
1.62k
| Patient Demographic
stringclasses 144
values | Mental Status Exam
stringclasses 139
values | Presenting Problem
stringclasses 229
values | Other Contexts
stringlengths 124
3.29k
⌀ | Question
stringlengths 24
595
⌀ | Choice A
stringlengths 2
294
| Choice B
stringlengths 2
321
| Choice C
stringlengths 1
284
| Choice D
stringlengths 3
414
| Potential Answers
stringlengths 34
1.12k
| Correct Answer
stringlengths 3
284
| Correct Answer (Letter)
stringclasses 4
values | Explanation For Correct Answer
stringlengths 77
2.25k
⌀ | Competency
stringclasses 6
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
601 | Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine | Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns. | Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed. |
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation. | Which of the following interventions would help Leah better understand her own enigmas? | Journaling | Trauma-informed cycle | Guided meditation | Empty chair technique | (A): Journaling
(B): Trauma-informed cycle
(C): Guided meditation
(D): Empty chair technique | Journaling | A | Through journaling assignments, Leah can identify, process, and build insight into her many reported enigmas as well as share them with you or others to receive feedback or review. The empty chair technique is supportive of helping Leah speak her truths to someone without them being there. Guided meditation can assist with reducing anxiety. Trauma-informed care is guided by the principles of safety, choice, collaboration, trustworthiness, and empowerment and is used to help educators break the cycle of client trauma and work to prevent client re-traumatization. Therefore, the correct answer is (B) | counseling skills and interventions |
602 | Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81) | Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games. | You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling. | You have attempted to arrange a family session with the mother, but she is unable to take off work to attend. The client arrives for his second session eager to share that he is “on green” this morning, which means the client’s behavior for the day has been good. You praise him for staying in his seat and keeping his hands and feet to himself. The client responds well to your praise. When engaging in a feelings identification activity, the client identifies feeling unhappy and worried when his father doesn’t show up for scheduled visitation. The client explains that his parents frequently argue about “how to take care of me” and “sometimes push each other.” He quickly abandons the feelings activity and asks if he can go back to class. You deny the client’s request to leave and instead give him the option of selecting another activity. The client refuses to do so and begins to kick your file cabinet repeatedly. He proceeds to knock papers off your desk. When redirected, the client’s behavior escalates. He quickly becomes inconsolable as he cries and yells, “I hate counseling, this school, and everyone in it!” Your client could benefit from a referral for in-home counseling, but the client’s insurance does not cover the services. Your supervisor asks you to find an in-network provider for the client | Your client could benefit from a referral for in-home counseling, but the client’s insurance does not cover the services. Your supervisor asks you to find an in-network provider for the client. In doing so, you adhere to which one of the following ethical principles? | Fidelity | Justice | Autonomy | Veracity | (A): Fidelity
(B): Justice
(C): Autonomy
(D): Veracity | Justice | B | Justice is an ethical principle, and social justice is a professional value associated with the ethical commitment to promote equal access to resources, rights, and opportunities for everyone. The ACA Code of Ethics (2014) defines justice as “treating individuals equitably and fostering fairness and equality” Equitable treatment includes having equal opportunities for accessible healthcare. Finding a provider that takes the client’s insurance is one way to practice the principle of justice. Doing so helps to improve outcomes, instill trust, and provide equal opportunities for the client and his family. The principle of veracity calls on counselors to conduct themselves truthfully and professionally. Autonomy is expressed when counselors support the client’s right to control the direction of their lives. Autonomy is the foundational principle of informed consent. Fidelity involves respecting commitments and honoring promises. Therefore, the correct answer is (B) | professional practice and ethics |
603 | Client Age: 74 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual and psychoeducation Presenting Problem: Memory impairment Diagnosis: Mild Neurocognitive Disorder (MND) Unspecified with Behavioral Disturbance (apathy and mood disturbance) 799.59 (R41.9) | Mental Status Exam: The client is appropriately dressed and cooperative. She is tearful at times and often glances over at her daughter when she is unsure of how to respond to a question. The client denies suicidal and homicidal ideations. She is oriented to the day, month, and year, but she could not recall the date or place. She recalls the city with prompting. The client’s sleep is fair, and her appetite is normal. She reports feeling sad most of the day, every day. To date, medical procedures used to determine the etiology of the client’s cognitive impairment have been inconclusive. She awaits an appointment for a positron emission tomography (PET) scan, which can help determine the presence of brain activity associated with Alzheimer’s disease. She denies substance use and says that she is a social drinker. Her judgment and awareness are fair, and she denies audio and visual hallucinations. Fam | You work in a mental health center and are conducting an initial assessment on a 74-year-old Caucasian female. The client and her daughter arrive today with a copy of the client’s recent neuropsychological evaluation. The evaluation shows cognitive functioning deficits, and the neuropsychologist has diagnosed the client with mild neurocognitive disorder (MND). The client and her daughter fear that her memory issues could worsen and impact her independence. The daughter has seen a gradual decline in the client’s memory, which coincides with episodes of depression. The client expresses embarrassment over her memory issues and states, “remembering the simplest things—like doctor’s appointments or paying bills—has started to become more and more difficult.” She states that she no longer participates in things she once enjoyed, including her book club, church services, and fitness classes. | You are on maternity leave, and your supervisor is covering your cases while you are out of the office. The supervisor meets with the client and daughter for the first time today and discusses the client’s progress and her treatment plan goals. The client and her daughter report measurable improvements with symptoms of depression and apathy. During today’s session, the supervisor also learns that you and the daughter went to high school together and share multiple acquaintances. There is no documentation in the client’s chart indicating that the risks and benefits of multiple relationships were reviewed with the client. At the end of the session, the supervisor asks the client for her copay. The daughter and the client state that you have “always just waived the copay,” indicating that the final bill would eventually be “written off by the agency.” The client has met her goals for reducing symptoms of depression and apathy; however, her memory has not improved | The client has met her goals for reducing symptoms of depression and apathy; however, her memory has not improved. How should you proceed? | Continue to work with the client and create treatment plan goals addressing memory impairment. | Discuss termination due to the client meeting her goals related to depression and apathy. | Continue to work with the client and renew treatment plan goals for depression and apathy. | Discuss referring the client to another professional who can address her memory impairment. | (A): Continue to work with the client and create treatment plan goals addressing memory impairment.
(B): Discuss termination due to the client meeting her goals related to depression and apathy.
(C): Continue to work with the client and renew treatment plan goals for depression and apathy.
(D): Discuss referring the client to another professional who can address her memory impairment. | Discuss referring the client to another professional who can address her memory impairment. | D | The best choice for this client is to refer her to another professional who can address her memory impairment. Because the client’s PET scan identified changes associated with Alzheimer’s disease, you would need to find a specialist, such as a neuropsychologist, who could better address the client’s cognitive impairment. Discussing termination is a possibility, but it precludes the client benefiting from additional resources. Continuing to work with the client on improving her memory impairment is also a possibility. However, research shows cognitive impairment is progressive, and there is little more the counselor can do to help with this. Renewing client treatment goals for depression and apathy is unnecessary because the client has already achieved them. This would only apply if the client met her short-term goals and the counselor and client decide together to focus on long-term goals. Therefore, the correct answer is (B) | treatment planning |
604 | Initial Intake: Age: 22 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: In a long-term relationship Counseling Setting: Adult inpatient psychiatric Type of Counseling: Individual | Mark was unable to complete a mental status exam as he was not speaking coherently and was displaying violent behavior towards hospital staff. The ER nurse interviewed Mark’s girlfriend, Erin. | Mark came into ER after his girlfriend Erin called 911 when Mark attacked someone on the bus.
History:
Erin told the ER nurse that Mark has been displaying increasingly irrational behaviors. Erin shared that Mark recently took a trip to Africa. Since then, Mark told Erin that he was hearing the voice of God, telling him that it was his responsibility to rid the world of evil. At first Erin noticed Mark staying up late at night, writing all his thoughts in a journal. When Erin read the journal, the content was incoherent. Erin also shared that Mark was recently put on probation at work for going into the women’s restroom. Mark told his boss that God told him to keep an eye on one of his coworkers. | null | When interviewing someone who is actively psychotic you should first asses? | Symptoms | Treatment | Diagnosis | Safety | (A): Symptoms
(B): Treatment
(C): Diagnosis
(D): Safety | Safety | D | Ensuring safety is a top priority. Considerations include seating arrangement, whether to have family members in the room and ensuring the comfort of the client. Although the diagnosis is helpful in determining effective treatment, it is the least important factor when interviewing someone who is actively psychotic. The assessment of severity of symptoms is necessary to establish level of functioning and help formulate treatment goals. Discussing treatment options is also important as part of the informed consent process and can be done after safety is assessed. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
605 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: College Campus Counseling Clinic Type of Counseling: Individual Counseling Presenting Problem: Depression and “Odd Behavior” Diagnosis: Bipolar 1 Disorder, Current Episode Manic Without Psychotic Features, Moderate (F31.12) | Mental Status Exam: The client states that she slept for 4 hours the night before, which was the most she has slept in one night in the past week and that she now feels tired for the first time. The client had dark circles around her eyes and was wearing sweatpants and a t-shirt with stains on it. The client is oriented to person, place, time, and situation. The client’s affect and speech are | You are a licensed therapist working on a college campus in the counseling center. A 20-year-old female client comes to counseling following 8 days of experiencing the following symptoms: little to no sleep most nights with the longest stretch of sleep being 2 hours, several middle-of-the-night shopping sprees, and distractibility. She reports that some of her college professors have called on her to stop talking during class and that she has not been doing very well in school this semester. The client identifies that she has felt this way before over the past 2 years and that this last time scared her because she was more aware of the negative impact it is having on her schooling. The client continues to relate that she also experiences depression at times and that she does not understand where it comes from but that it happens for a few weeks at a time every few months. When in a depressive episode, the client experiences a depressed mood more often than not, decreased enjoyment of activities, hypersomnia, fatigue, and a significant decrease in appetite. | You meet with the client during your regularly scheduled session. The client says that the manic behavior has stopped and that she is starting to enter a depressive episode. The client identified mild depressive symptoms including a down mood, difficulty enjoying activities, and fatigue. The client states that she still has not contacted the psychiatrist because she does not know if she is ready for medication. You process this thought with the client and identify that she is worried about the side effects of the medication. You encourage the client to meet with the psychiatrist and be open about her worries in order to get more information on the medication options. The client expresses worry that her academic success has been affected by cycling moods. The client’s grades are currently dropping, and she says that she does not have control over them. You empathize with the client and begin to talk about behavioral and cognitive interventions to improve functioning | Based on the information that you already have, which of the following would be a clinically indicated behavioral intervention to manage increasing depressive symptoms? | Encourage the client to spend time with friends because this makes her happy. | Encourage the client to follow up with the psychiatrist in order to discuss medication for depression. | Encourage the client to plan out pleasurable activities that she has enjoyed in the past, and mention that she should do them even if she feels like she will not enjoy them. | Develop an exercise routine because exercise focuses on general well-being and can improve mood by releasing endorphins. | (A): Encourage the client to spend time with friends because this makes her happy.
(B): Encourage the client to follow up with the psychiatrist in order to discuss medication for depression.
(C): Encourage the client to plan out pleasurable activities that she has enjoyed in the past, and mention that she should do them even if she feels like she will not enjoy them.
(D): Develop an exercise routine because exercise focuses on general well-being and can improve mood by releasing endorphins. | Encourage the client to plan out pleasurable activities that she has enjoyed in the past, and mention that she should do them even if she feels like she will not enjoy them. | C | Based on the information provided, it would be most beneficial to encourage the client to plan activities that she knows she has enjoyed in the past. The cognitive distortion associated with assuming that she will not enjoy herself is called fortune-telling because she is assuming an outcome without knowledge to support the assumption, and she may in fact enjoy things more than she thinks, even if it is not to the extent that she used to. Exercise can improve mood and well-being, but the client has not expressed any interest in this activity. The client already spends time with friends and should continue to do so. The client reports not feeling ready to take medication, so this is an ongoing discussion. Therefore, the correct answer is (B) | treatment planning |
606 | Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate | Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent | You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.” | . Family and History: The client is an only child and has never been married. She describes her relationship with her parents as “close until recently.”She and her family belong to a Christian evangelical church, and her family does not accept the client’s sexual orientation\. Her father is an accountant without any known mental illness. The client’s mother has been diagnosed with depression and anxiety. When growing up, the client states her parents placed a strong emphasis on how things looked on the outside. She feels she has failed her parents and carries shame and guilt over her body weight and sexual orientation | Based on the client’s clinical presentation, what topic should be discussed to help develop initial treatment plan goals? | Social isolation and other interpersonal deficits | The effects of internalized biphobia | Cognitions associated with depressed mood | Behaviors maintaining maladaptive eating | (A): Social isolation and other interpersonal deficits
(B): The effects of internalized biphobia
(C): Cognitions associated with depressed mood
(D): Behaviors maintaining maladaptive eating | Behaviors maintaining maladaptive eating | D | You would first identify behaviors maintaining maladaptive eating. Goals related to the client’s maladaptive eating patterns are prioritized because binge-eating disorder is the client’s primary diagnosis, and the client has expressed the desire to stop binge eating. There are several areas of exploration for this client, including depressive symptoms, her relationship with her family since coming out, her spirituality, and binge eating. The client prioritized the focus of treatment by stating, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating” While treatment engagement is generally accomplished using a strengths-based approach, best practices for eating disorders suggest identifying and changing maladaptive eating first, followed by addressing any underlying issues. Therefore, the correct answer is (B) | treatment planning |
607 | Name: Dave Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders;Substance Use Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder; F10.99 Unspecified Alcohol-Related Disorder Age: 42 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client presents at the intake session biting his nails and cannot keep his legs from shaking. He feels anxious about his wife and work. He continually places his hands on his head and complains of headaches and nausea. He admits to drinking a bit more than he should. He denies thoughts of self-harm but sometimes wishes that he could "disappear." | First session You are a counseling intern at an agency that works with clients from various socioeconomic backgrounds. Your client is a 42-year-old married male massage therapist who owns two therapeutic massage practices. Over the past nine months, his business has been reduced by fifty percent. He is having great difficulty paying the bills for the business, and he has exhausted his personal savings. His wife is currently not working due to a back injury. He has difficulty concentrating during the day and is irritable around his employees, friends, and family. He states that he drinks "too much" in order to relax at night and admits that his hangover adds to his anxiety the next day. His wife has begun to complain, and their relationship has been strained over the past three months. The client is concerned about paying for the sessions due to financial issues. He offers to exchange massage sessions for therapy. The client is aware that anxiety and alcohol use are impacting his work and family life negatively, but he does not know how to get a handle on them. He reports feeling overwhelmed with worry about the future of his business and whether he will be able to continue providing for his family. The client has been avoiding people lately, including old friends, and only sees his mother occasionally due to her health problems. In terms of self-care, the client acknowledges that he tends to put everyone else's needs before his own, which leads to feelings of exhaustion and anxiety. Additionally, he finds it difficult to recognize or accept compliments from others and has difficulty expressing gratitude for their help. During the intake session, you identify anxiety as one of the primary issues the client is seeking help with. You also discuss the role that alcohol is playing in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to developing a plan with the client for addressing these issues, such as scheduling regular self-care activities, limiting or eliminating alcohol use, and exploring cognitive behavioral therapy techniques for managing anxiety levels. Fourth session The client presents for his fourth session. You were able to work out a payment plan with him which has relieved his immediate concerns about paying for therapy sessions. However, he reports ongoing tension about finances and says that his his wife packed a bag to leave after a "big fight" about money. She told him she needs some space to see if she wants a divorce. The client breaks down and begins to cry and shaking uncontrollably. While looking at the ground he laments, "I don't know what to do. It wasn't always like this. We used to be happy, but now I'm just stressed and worried about everything. I'm never going to be able to make enough money to support my family." He tells you that he works hard to provide for his family, but his wife does not appreciate or support him. He has been drinking more but knows that it is not helping. He has decided he needs to make some lifestyle adjustments; he is ready to make changes and work on his issues. In the session, you provide a supportive environment, helping your client to see his anxiety from a place of self-awareness and empowerment. You offer him concrete strategies for managing anxiety including relaxation techniques, cognitive restructuring, and grounding exercises. You also explore how he can work towards building better communication with his wife by expressing himself in an assertive yet respectful way. You both discuss how alcohol serves as a distraction but ultimately leads to additional anxiety. Together you come up with a plan that includes reducing the amount of alcohol he consumes, engaging in positive self-talk, and scheduling weekly activities such as going on walks to help him reduce stress levels. At the end of this session, you encourage your client to continue making strides towards his goals and remind him of the progress he has already made. You assure him that anxiety is something that can be managed with regular practice and together you will continue to work towards positive change. Eighth session The client has been seeing you once a week for the last two months. Today, he appears calm, and his thoughts are coherent. The client tells you that he has not completely abstained from alcohol, but his use has significantly decreased. He reports that he went to a virtual AA meeting but did not find it helpful, so he signed off. The client opens up and states, "I think one of the reasons I am anxious is because I am having an affair. Ever since my wife hurt her back, we have not been intimate." The client's speech becomes more rapid, and he begins to lose eye contact as he discloses the details of his affair to you. Your client tells you, "I'm not happy with my wife, either sexually or emotionally. The new woman I'm seeing understands me, and I don't want to drink when I'm around her. She helps me forget everything that causes me stress." In response to your client focusing on the positives of his affair, you engage the client in a discussion to explore the issue from other perspectives. You ask questions like, "What do you think would happen if your wife found out about your affair?" Your client pauses for a moment and looks down, and then says, "I'm not sure. I care about my wife, but I don't know if she will ever be able to understand me in the way that this other woman does. I feel like I'm trapped." You listen empathically as your client expresses his feelings of anxiety, despair and confusion. You provide clarification when necessary and strive to help your client gain insight into his thoughts and behaviors. In the session, you explore the client's anxiety and how it has been related to his affair. You address underlying issues that may be contributing to the anxiety such as unresolved feelings of guilt or fear of being discovered. You emphasize that anxiety is often a sign of trying to avoid uncomfortable emotions and situations, but acknowledging them can help him understand anxiety in a different way. You also talk about the role alcohol has played in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to incorporating strategies to address these issues in his treatment plan, such as scheduling regular self-care activities and exploring the relationship between his thoughts and behaviors. Toward the end of this session, the client appears calmer and confident in his ability to make positive changes. As you are wrapping up the session, the client confides to you that ever since he started having an affair, he has found himself sexually attracted to his daughter. He says, "It's just kind of exciting to peek in the bathroom and watch her in the bathtub. But I would never touch her! It's just a passing thought. I know that I need to stop. The thrill of my affair is satisfying enough." | The client has been married for ten years. He and his wife have two children together, a son, age 10, and a daughter, age 12. The client does not speak to his father, who divorced his mother when he was four years old. The client and his mother have a good relationship. The mother lives 15 minutes away from the client and helps his wife with the children. During the past nine months, his massage therapy practice revenue has decreased by fifty percent, and it has been difficult to pay the bills. The client has exhausted all personal savings. The client is the sole income provider for his family, as his wife is not working while recovering from a back injury. | You tell your client, "I have some pretty strong feelings about affairs. My father cheated on my mother, and I feel that having an affair is a cowardly way out of a marriage." What has transpired between you and the client? | You followed the ethical rule of justice. | You have overly self-disclosed due to countertransference. | You followed the ethical rule of fidelity. | You told the client how you feel to broaden his perspective. | (A): You followed the ethical rule of justice.
(B): You have overly self-disclosed due to countertransference.
(C): You followed the ethical rule of fidelity.
(D): You told the client how you feel to broaden his perspective. | You have overly self-disclosed due to countertransference. | B | This is correct. The client brought up feelings in you and caused a reaction. He reminded you of your father (countertransference), and you reacted by self-disclosing too much of your own history. Therefore, the correct answer is (A) | professional practice and ethics |
608 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | The client began a new medication, which has helped with his delusional thinking. He continues to hear voices but reiterates that he does not hear command hallucinations. The client is able to focus on interpersonal relationships and has shown interest in obtaining part-time employment. He reports that he continues to benefit from group therapy. He has identified decreasing maladaptive thoughts and improving social skills as long-term treatment plan goals | Which cognitive-behavioral technique (CBT) can be used to investigate alternative explanations for the client’s delusions? | Scaling questions | Symptom analysis | Peripheral questioning | Unified detachment | (A): Scaling questions
(B): Symptom analysis
(C): Peripheral questioning
(D): Unified detachment | Peripheral questioning | C | Peripheral questioning is used to investigate alternative explanations for the client’s delusions (eg, “How do you know the shadow man is poisoning your food?. What methods would he use to do this?”). This technique focuses on the client’s specific symptoms to understand their origins and plausibility. Slowly, incremental reality testing is used to present hypotheses for alternative explanations. This technique helps reduce blame and enhances the therapeutic alliance. Scaling questions are associated with solution-focused brief therapy and are used to help clients track progress towards identified goals. For example, “Where are you on a 1-10 scale concerning the resolution of your problem?” Unified detachment is a technique used in integrative behavioral couple therapy (IBCT) involving communication in a detached and non-accusatory manner. Symptom analysis is a Jungian therapy technique used to help individuals achieve a state of individuation and self-realization. Therefore, the correct answer is (C) | counseling skills and interventions |
609 | Initial Intake: Age: 14 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Hispanic - Mexican American Relationship Status: Single Counseling Setting: School-based Type of Counseling: Individual | Raul presents as irritable and anxious, with congruent mood and affect. Raul is casually dressed, appears to be overweight for his age and height, and is sweating with nervous hand motions. Raul has difficulty making eye contact, takes long pauses prior to answering questions, and often asks you to repeat the question after a long pause. Raul denies SI/HI or hallucination/delusion. He refers to an incident in his past he considers to be “trauma” but is uncomfortable discussing with you. When asked about his father, he sheds a tear which he immediately wipes away and returns to a scowl on his face with arms crossed, saying “there’s nothing to talk about.” Raul does admit to several instances of aggression with others such as “shoving a kid,” “kicking a desk” and “cursing out the principal.” You ask if he has ever been on medication for ADHD. He says, “No, I don’t think so. My doctor told my mom a few times to fill out some forms, but I don’t think she ever did.” | Diagnosis: Attention-deficit hyperactivity disorder, predominantly inattentive type (F90.0), Conduct disorder, unspecified (F91.9)
You are a counseling intern working for an agency that sends counselors into grade schools to work with their students on longer-term mental health issues. Raul is referred to you by his assistant principal for multiple in classroom infractions of interrupting, bullying, and being a “class clown.” In meeting with Raul and his mother, she shares that the principal accused Raul of bullying kids on the bus, and defacing property. She says, “Kids will be kids, they’re probably just too sensitive.” Raul’s mother works full-time and has an active social life, leaving Raul to stay at home alone frequently after school or on weekends. His mother appears very casual and does not seem concerned about Raul’s behaviors. She does mention Raul’s diagnosis of ADHD was given by his pediatrician, but he has never received psychiatric services. In front of his mother, Raul is quiet and acts well-behaved; after his mother leaves, he tells you he gets frustrated with her for leaving him alone but would never admit it to her directly. He refuses to state that he feels lonely, sharing that he spends most of his alone time playing live video games with other people across the country. He also denies bullying other kids. | Education History:
Raul’s teachers inform you of his behaviors throughout his freshman year in high school, that have according to them been ongoing since Raul’s middle school years. Raul is often reported for being inappropriate in class by making impulsive remarks to try and get others to laugh, disrupting the class, or falling asleep and appearing distracted. The school is concerned with his academic progress and has discussed moving his status up a higher-level Tier so he can be monitored further and made available to special programming geared towards students in jeopardy of failing.
Family History:
Raul lives with his mother and occasionally one of his mother’s boyfriends who come and go intermittently. Raul has one older sister who lives in the next town. Raul’s father lives in Mexico with several of his half and step siblings with whom Raul has minimal contact. Raul’s father is unable to enter the U.S. and has been absent most of Raul’s life. Raul reports his father is an alcoholic, but that where he lives, they “don’t think of things like that” because that is what his father told him. Raul’s grandmother also lives in Mexico but has been a continual presence in his life via phone calls, mail, and is his primary caretaker when he does visit Mexico, which has occurred twice. | Reflecting on your conversation with mom, you recall that Raul's primary pastime is playing video games. What can this piece of information help you understand about Raul? | He uses dissociation for coping. | He can be motivated through use of gaming language. | Video games worsen his ADHD symptoms. | He doesn't really have ADHD. | (A): He uses dissociation for coping.
(B): He can be motivated through use of gaming language.
(C): Video games worsen his ADHD symptoms.
(D): He doesn't really have ADHD. | He uses dissociation for coping. | A | If the only activity Raul engages in on his own time involves a distraction from his reality, it is reasonable to assume this is what he turns to for escape, release, comfort, enjoyment, and/or safety. This is vitally helpful in treatment planning and providing interventions to help Raul learn to accept his reality, adapt to his circumstances, and cope with his distress, to prepare him for a successful future in an unpredictable world. One can control several factors in video gaming, giving a false sense of security and predictability as one navigates the rules of the game. When met with unprecedented challenges or failure, the consequences are minimal and thus capable of being managed with little effort. Gamers may experience and feel losses or frustrations in games passionately, resulting in large expressions of emotions and often impulsive behavior such as throwing their controller across a room; these are expressions of much deeper emotional conditions that have found a rather controllable outlet. While overstimulation may negatively affect an individual with ADHD, some games have been proven to support certain cognitive functions that can help with certain ADHD conditions when well-managed with boundaries and a balance of other activities. The ability to hyper-focus on gaming does not rule out ADHD; some people think if a child can focus on something like their video games, they could not possibly have ADHD. However, the deficits in the disorder relate to how well a child can pay attention to low interest activities or content. Children with ADHD can develop an obsession with high-interest activities due to their cognitive processing inflexibility. There is no evidence to support answer c) would be effective, although use of this idea in interventions would not be harmful. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
610 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out." You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety. | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | What would be considered a long-term goal for this client? | Resolve the core conflict that is the cause of the client's anxiety | Implement coping strategies to reduce anxiety and manage panic symptoms | Increase presence at school and job | Articulate a clear understanding of the manifestations and causes of panic attacks | (A): Resolve the core conflict that is the cause of the client's anxiety
(B): Implement coping strategies to reduce anxiety and manage panic symptoms
(C): Increase presence at school and job
(D): Articulate a clear understanding of the manifestations and causes of panic attacks | Resolve the core conflict that is the cause of the client's anxiety | A | Resolving the core conflict that is causing the client's anxiety will be a long-term goal of therapy. By exploring his memories and addressing the issues at their root, your client can gain insight into why he feels anxious, develop strategies to manage it, and ultimately work toward overcoming it. Therefore, the correct answer is (C) | treatment planning |
611 | Name: Barry Allen Clinical Issues: Behavioral problems Diagnostic Category: V-codes Provisional Diagnosis: Z62.898 Child Affected by Parental Relationship Distress Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in DC Comic attire and lives for cosplay. He is well groomed and sensitive to his appearance. Eye contact is minimal. His behavior is tense and purposeful. He demonstrates a limited affect and is minimally responsive. The client denies any current suicidal or homicidal ideation. | First session The client and his father present at the community counseling center where you practice as a marriage and family therapist. The father reports that his son has not been doing his homework or contributing to family chores. The client's mother is "at her wit's end" and told her ex-husband to get their son help. The school has called several times out of concern for the client's withdrawn behavior. He is not paying attention, is sleeping in class, and appears sad and irritable. You notice that he is disinterested, withdrawn, and does not want to be involved in therapy. The father minimizes his son's behavior and does not want any responsibility related to therapy. At the same time, he wants you to improve his son's attitude. Through open-ended questions and careful exploration, it is revealed that the client has been having difficulty establishing relationships with peers and adults. He has been feeling overwhelmed by his parents' relationship distress and his mother's new family dynamics. Furthermore, he has been struggling to manage the transition of living in two different homes between his parents. His father reports that his son appears to be increasingly isolated and has difficulty regulating his emotions. The client reveals that he is feeling lonely, depressed, and anxious due to the stress and uncertainty of his parents' relationship issues. He feels as though he is caught in the middle of his parents’ conflict and unable to meet their expectations. It appears that the distress caused by his parents’ relationship is affecting the client's overall wellbeing. You explain to the client and his father that therapy can help him process his feelings, build healthy coping strategies, and develop better communication skills with both of his parents. Third session During the previous session, you met with the client and his father. You recommended meeting with the client for weekly individual sessions with parental check-ins periodically. Today, you are seeing the client by himself. You use a video game to attempt to engage with the client; he is responsive. While the client is playing the video game, you proceed to gather information. You determine that his major difficulty is his struggle with rule inconsistencies between his parents' homes. He says that his father allows him more freedom than his mother, which results in frequent arguments. When the client is at his father's house, he is allowed to stay up later and watch television for longer periods of time. His mother has stricter rules about bedtime and screen time, which creates tension between the client and his father when he visits his mother's home. The client struggles with navigating these different expectations from both of his parents, leading to feelings of confusion and depression. Additionally, the client expresses frustration over feeling like an unwelcome guest in his soon-to-be step-family members' home due to their lack of acceptance toward him. The client tells you that his soon-to-be step-siblings are "mean" and tease him. He tells you that sometimes he thinks about running away and fantasizes that he has a special power like "The Flash, the superhero who is the fastest human on Earth." You validate his feelings and share a brief personal story with him about who your favorite superhero was when you were his age. You explain to the client that it is important for him to understand his emotions, and help him think of healthy ways to cope with them. You mention the idea of him joining the school track team. The client appears excited about your suggestion. You also explain how communication is key in creating successful relationships. Since he is feeling overwhelmed by all the rule inconsistencies between his parents' homes, you suggest developing a consistent rule system with both of his parents. This way, the client can feel secure in knowing what kind of behaviors are expected from him regardless of which home he visits. You observe the client as he processes all that you have discussed during the session. You encourage him to continue talking and share his thoughts with you. He acknowledges that it is difficult for him to switch between his parents' homes, but he feels a little more hopeful after talking with you today. You remind him of the importance of communication, expressing his needs in a respectful manner, and maintaining healthy boundaries with others. | The client's parents have been divorced for five years. The client's father shares parenting responsibilities of his only son, age 13, with the client's mother. The father, who is not currently in a relationship, "tries to get along" with his ex-wife but finds this challenging. The client's mother is living with her new fiancé. The fiancé is twice divorced and has three children from previous marriages. Both sets of the client's maternal and paternal grandparents have passed away. | In response to the client's statement about The Flash, you suggest that he join the track team. What method are you employing with your suggestion? | Paradoxical intention | Building on the client's strengths | Humor as part of the therapy | Challenging the client to be more realistic | (A): Paradoxical intention
(B): Building on the client's strengths
(C): Humor as part of the therapy
(D): Challenging the client to be more realistic | Building on the client's strengths | B | Sometimes defense mechanisms can be helpful to move us forward in our effort to change. Thinking he is Flash is not all that bad a fantasy, and now maybe he can do something about it by actually joining the track team himself. Does this sound a little far-fetched?. Maybe, but maybe not. You will want to caveat the attempt with some realism and reality, but at the same time do so with encouragement to try something new. Therefore, the correct answer is (A) | counseling skills and interventions |
612 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | Considering the first session notes, which of Mary's issues would you attempt to discuss with her next? | shopping addiction | stress from dog's health | redirect back towards social phobia | complex grief | (A): shopping addiction
(B): stress from dog's health
(C): redirect back towards social phobia
(D): complex grief | stress from dog's health | B | Mary has just told you her here-and-now functioning is being negatively affected due to stress that her only live-in companion is not doing well. Address this with Mary right away as it demonstrates compassion and concern, helps you better understand her feelings and fears, and focuses in on another stressor that could be driving maladaptive behavior. Mary presents as in denial over her shopping patterns which may be driven more by perfectionism, compulsion out of boredom, and lack of life satisfaction more so than addiction. This would require further processing, but Mary does not have insight into this considering her response to your question during session. Changing the topic entirely to a different treatment plan goal or projecting her fears about her dog onto other known issues such as grief are both not the most compassionate and empathic choices. Therefore, the correct answer is (B) | counseling skills and interventions |
613 | Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate | Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent | You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.” | The client has made steady progress toward reducing maladaptive eating. After several weeks of collecting self-monitoring data, you and the client successfully identify patterns that maintain the problem of binge eating. The client’s depressive symptoms have improved, and she is seeking interpersonal connections. She has set appropriate boundaries with her family and distanced herself from their church. The client briefly attended a more liberal church, experienced biphobia, and did not return. She explains, “In my parent’s church, I’m not straight enough. In the LGBTQ community, I’m not gay enough.” You have introduced her to dialectical behavioral therapy, and she attributes mindfulness to improved depressive symptoms. Which Dialectical Behavior Therapy (DBT) module teaches radical acceptance using alternative coping skills (e\. g | Which Dialectical Behavior Therapy (DBT) module teaches radical acceptance using alternative coping skills (e.g., self-soothing)? | Distress tolerance | Interpersonal effectiveness | Emotional regulation | Core mindfulness | (A): Distress tolerance
(B): Interpersonal effectiveness
(C): Emotional regulation
(D): Core mindfulness | Distress tolerance | A | Distress tolerance is one out of four DBT skills modules. Distress tolerance teaches clients to accept the present situation and employ coping or survival skills such as self-soothing, distraction, and weighing the pros and cons. Radical acceptance involves adopting a nonjudgmental stance and accepting or tolerating the outcome. The DBT module of core mindfulness is used to help the client remain fully aware and in the present moment. Interpersonal effectiveness uses assertiveness strategies and conflict resolution skills to help clients with interpersonal issues. Lastly, emotional regulation helps clients learn how to accurately label current feelings, decrease reactionary responses, and decrease the intensity of emotional experiences. Therefore, the correct answer is (D) | counseling skills and interventions |
614 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | Since the fourth session, child protective services investigated the client’s abuse allegations and determined that they were unfounded. You discuss this with the client and he says he was lying because he was mad at his parents that day. You praise the client for being forthright today regarding the allegations and discuss how false allegations can be incredibly harmful to others and can strain his relationship with his parents further. You and the client process several situations similar to this in which he avoided responsibility. You empathize with the client and support his reflection on his behavior. The client’s parents have not paid for the past three sessions | The client’s parents have not paid for the past three sessions. All of the following are important considerations, EXCEPT: | Inform the client in a timely fashion of your intention to use a collections agency. | Waive the session payments because the client is unable to afford them and you want to preserve the counseling relationship. | Offer the client the opportunity to pay for the past three sessions. | The policy should be covered in your informed consent document, and you should follow the agreed-upon terms. | (A): Inform the client in a timely fashion of your intention to use a collections agency.
(B): Waive the session payments because the client is unable to afford them and you want to preserve the counseling relationship.
(C): Offer the client the opportunity to pay for the past three sessions.
(D): The policy should be covered in your informed consent document, and you should follow the agreed-upon terms. | Waive the session payments because the client is unable to afford them and you want to preserve the counseling relationship. | B | The client has agreed to certain payment expectations as outlined in the informed consent documents and is not paying as agreed. You are able to refrain from waiving the payments if you would prefer because they have been consented to. Informing the client of intentions to use a collections agency, allowing the opportunity to pay for recent sessions, and including this information in the informed consent are all important ethical considerations in this situation, according to the ACA Code of Ethics. Therefore, the correct answer is (D) | professional practice and ethics |
615 | Age: 27 Sex: Female Gender: Female Sexuality: Declined Ethnicity: Hispanic/African American Relationship Status: Single Counseling Setting: Community Agency Type of Counseling: Individual | The client presents as her stated age with positive signs of self-care related to hygiene and dress. She appears overweight for height as noted in her intake. Her mood and affect are congruent and she appears to be cooperative and forthcoming in her responses. She demonstrates no retardation, spasticity, or hyperactivity of motor activity. She is oriented and demonstrates no unusual thought processes or patterns. Her insight is intact and she identifies goals for therapy. She reports no suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a community agency that provides counseling. Your client presents with a history of convictions for felony criminal offenses in her early 20s, of weight loss and gains since college, and currently rates herself as approximately 50 pounds overweight. She describes herself in years past as “fat,” “ugly,” and “grotesque.” She reports one long term relationship during high school and college, with a male she tells you was “manipulative, controlling, and emotionally abusive. She reports not “dating-dating” since their break up six years ago. She does report that recently she has engaged in self-destructive behaviors with different people in the context of online relationships. She states that in several cases, she has met men and women online and used elaborate methods, including using multiple telephone numbers and creating false names and life events to establish relationships with these individuals. Several relationships ended abruptly when the individuals, both male and female, made concerted efforts to meet the client, at which time she disclosed the truth to them. She tells you that she feels very badly about what she did, particularly because she had been helping each of the people with different problems in their lives, including one of the women with an abusive spouse, and she believes now these people will have no help. She attended counseling for several months three years ago but reports she did not tell the counselor everything. Today she tells you that she is now in a professional graduate program for counseling and wants to be open about everything so she can “finally get her life in order.” | Family History:
The client reports her support system as several male and female friends. She feels close to these people though she says they sometimes irritate her. She describes her father as distant and her mother as strict and controlling. She states she and her siblings were punished frequently for not following their mother’s strict expectations for “how young women and young men should act.” She states she and her siblings were required to engage in daily exercise; always dress in “their Sunday best” during childhood; and focus on dieting, food intake, and weight ideals. She tells you she daily engaged in binging and purging from age 13 to age 20, but never told anyone or saw a doctor for this. She tells you that she has not binge/purged for the past five years. She states that her sister did the same and still struggles with it, and two other siblings are in treatment for alcohol and methamphetamine addiction. Additionally, the client tells you that both of her maternal and paternal grandparents have histories of alcoholism, and she smiles when telling you that one of her grandparents was imprisoned for criminal behavior and “is connected.” She says that several other maternal and paternal relatives have criminal convictions. | In considering concurrent treatment for this client, which of the following would be most helpful? | Referral to process-oriented group counseling | Referral to family doctor for monitoring weight | Referral to psychoeducational group counseling | Referral to psychiatry for medication evaluation | (A): Referral to process-oriented group counseling
(B): Referral to family doctor for monitoring weight
(C): Referral to psychoeducational group counseling
(D): Referral to psychiatry for medication evaluation | Referral to process-oriented group counseling | A | Process-oriented groups focus on the here-and-now relationships between the members of the group. They are longer term groups where members end up recreating their interactions with others through the process of transference with other members of the group. Process-oriented groups allow for members to provide positive and negative feedback to each other to promote personality change and growth. This will be helpful for the client to have others speak directly to her interpersonal interactions with people and how it is received by others. Referring her to a psychoeducational group would be less helpful as psychoeducational groups teach about a specific diagnosis, coping skill, or other strategy for self-improvement. Psychoeducational groups do not allow members to confront other members as they can in process-oriented groups. This client does not need referral to psychiatry as she has no diagnoses that requires medication. Additionally, a referral to her family doctor for weight monitoring moves the focus of counseling to her bulimia, which is in full remission. Since she is not engaged in disordered eating, there is no reason for monitoring weight from a counseling perspective. Therefore, the correct answer is (C) | counseling skills and interventions |
616 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | What kinds of activities can you do with Mary related to her grief? | assign journal writing assignments | listen to music with her | EMDR | guided art projects | (A): assign journal writing assignments
(B): listen to music with her
(C): EMDR
(D): guided art projects | listen to music with her | B | Mary has mentioned in her intake that country music calms her. Incorporating this positive coping method into her treatment is a great way to help her associate counseling with something that already brings her peace. Through this practice you can offer to listen to memories of her loved ones, share stories, or even teach mindfulness. Writing or art would be too challenging for Mary as she has already shared that she developed arthritis and has limited use of her hands for intricate tasks. EMDR is eye-movement desensitization and reprocessing, a trauma therapy for those prepared to engage in intense focused treatment to reduce symptoms of trauma reactions. This might be something useful for her eventually either through a referral or if you become certified to provide this service. Therefore, the correct answer is (D) | counseling skills and interventions |
617 | Initial Intake: Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: VA Type of Counseling: Individual | Carl came to the intake session alone and angrily stated, “I really don’t know why they are making me come to therapy - it doesn’t help anyway.” Carl appeared edgy throughout the interview and responded to questions with minimal effort.
| Carl is a 38-year-old Army Veteran who is attending counseling at the local VA. Carl was referred after he was arrested for a DUI last week.
History:
Carl has been on four deployments to the Middle East, he returned from the most recent tour 11 months ago, after he was injured during a military strike. Some of his team members were injured as well.
Since his return, Carl and his civilian wife, Lori, have discussed separation because of their frequent arguing and Carl’s drinking. Carl began drinking when he was deployed and since then has used it as a coping mechanism to combat the frequent flashbacks and nightmares that he gets. Carl and Lori mostly argue about money since Carl has not been able to sustain employment as a construction worker because of his drinking problems. Carl has been arrested several times for assault and disorderly conduct. Carl recently assaulted his last counselor after he had made a comment about Carl not being able to sustain work.
The counselor thanked Carl for his service and reviewed with him that he was referred as a part of his probation. He must attend individual therapy and an anger management group for veterans. The counselor then described to Carl the purpose of the meeting and what would be reviewed and discussed during their time together. This included the intake paperwork, including informed consent and several assessments. | null | All of the below therapeutic techniques may be beneficial to treat Carl's PTSD symptoms, except? | Pet therapy | Exercise program | Anti-epileptic medication | Anger Management | (A): Pet therapy
(B): Exercise program
(C): Anti-epileptic medication
(D): Anger Management | Anti-epileptic medication | C | Anti-epileptic medication has not been proven effective to treat PTSD. SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) have been found to be effective for PTSD. Anger management skills can teach Carl coping skills to manage his reactions. Pet therapy has also been found to be an effective form of intervention for combat veterans diagnosed with PTSD. Exercise also helps to release endorphins which can help combat Carl's irritability and aggression. Therefore, the correct answer is (D) | treatment planning |
618 | Initial Intake: Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age and is dressed appropriately for the circumstances. She identifies her mood as “somewhat anxious” and her affect is labile and congruent. She is noted to rub her hands together at times and she appears uncomfortable at times as she talks about herself. She demonstrates good insight, appropriate judgment, memory, and orientation. She reports no history of trauma, suicidal thoughts, or harm towards others. | You are a non-Hispanic counselor in a private practice setting. Your client is a 42 year old female who reports that she has been working for the same accounting firm for 10 years and was recently laid off due to a downturn in the economy. She tells you that prior to this firm, she worked in a company doing managerial accounting that she joined right after college. She says that she has liked the people that she has worked with but over the past several years she has enjoyed her work less and less. She reports that she is upset to have lost her job but, in some ways, she sees it as an opportunity to find something else she is more passionate about, but she has no idea where to start. She does say that she wants a job and work environment that is a better fit for her personality. She also tells you that she is afraid that she is too old to begin again or that she doesn’t have “what it takes” to begin a new career. | Family History:
The client reports no significant family history related to mental health issues or relationship problems. The client tells you that she chose accounting in college because she grew up in a small town and her parents told her that she needed a skill that would help her support herself. Additionally, she states that she has been married for 19 years and has a good relationship with her spouse. She tells you that he is supportive of her exploring new careers but that her income is helpful for the family and it is important that she works. | Which of the following is the most appropriate to discuss with the client at the beginning of counseling? | Career counseling can include personal issues that impact career and career decisions | Career counseling focuses only on exploring career and occupational choices | Career counselors are not mental health counselors | Career counseling is a specialty area that only some counselors are trained to provide | (A): Career counseling can include personal issues that impact career and career decisions
(B): Career counseling focuses only on exploring career and occupational choices
(C): Career counselors are not mental health counselors
(D): Career counseling is a specialty area that only some counselors are trained to provide | Career counseling can include personal issues that impact career and career decisions | A | Career counseling focuses on career decisions and choices as well as any personal or mental health issue that impacts a client's career satisfaction or career decision-making. Career counseling, therefore, does not focus only on exploring career and occupational choices. Responses c and d are incorrect because all mental health counselors are trained in career counseling, and licensure exams require competence in career theories and career-oriented models for counseling. Therefore, the correct answer is (B) | counseling skills and interventions |
619 | Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0) | Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f | You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it. | The client discusses how his case manager has gotten him into a shelter and is currently working on securing housing for him. The client processes feelings surrounding the shelter and has begun a detox program for his fentanyl addiction. The client verbalizes that he is experiencing anxiety surrounding being at meetings with the case manager, talking with other residents, reintegrating into a “more normal life,” and worrying about whether he can ever have a relationship with his kids or ex-wife if he gets sober. Through processing, you realize that this anxiety was present prior to drug use and that he has experienced anxiety throughout his life | All of the following are considered short-term objectives for therapy EXCEPT: | Identifying triggers for anxiety in order to understand the root of the anxious thoughts | Learning and implementing coping skills with a resulting decrease in anxiety and improved functioning | Learning and implementing strategies to delay the onset of anxiety following a trigger | Using the Generalized Anxiety Disorder-7 item (GAD-7) scale to determine the client’s baseline anxiety and progressing toward reduction of anxiety symptoms | (A): Identifying triggers for anxiety in order to understand the root of the anxious thoughts
(B): Learning and implementing coping skills with a resulting decrease in anxiety and improved functioning
(C): Learning and implementing strategies to delay the onset of anxiety following a trigger
(D): Using the Generalized Anxiety Disorder-7 item (GAD-7) scale to determine the client’s baseline anxiety and progressing toward reduction of anxiety symptoms | Learning and implementing coping skills with a resulting decrease in anxiety and improved functioning | B | Learning and implementing coping skills with a resulting increase in functioning would be considered a long-term goal for therapy because many steps need to occur prior to this result. Identifying triggers, monitoring the client’s progress with the GAD-7, and teaching strategies to delay the onset of anxiety following a trigger are appropriate short-term goals that can generally be accomplished in the immediate weeks of initiating therapy. Therefore, the correct answer is (A) | treatment planning |
620 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | A physical cause of drug addiction is? | A person's biological makeup | Alcohol flush reaction | Expectations of social success | Failure of parental guidance | (A): A person's biological makeup
(B): Alcohol flush reaction
(C): Expectations of social success
(D): Failure of parental guidance | A person's biological makeup | A | The physical causes of drug addiction include the pleasurable feeling drugs may cause, craving and genetic vulnerability, as well as exposure to substances. Expectations of social success and failures of parental guidance are psychosocial causes of drug addiction. Alcohol flush reaction is a physical reaction to alcohol seen primarily in people of Asian descent in which the body cannot break down the enzymes in alcohol. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
621 | Initial Intake: Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Chinese Relationship Status: Single Counseling Setting: College Counseling Center Type of Counseling: Individual | The counselor noticed that Darrel’s clothes look disheveled, he had bags under his eyes and made very little eye contact. When asked, Darrel stated that he was working late the day before and he just needed to rest.
| Darrel is an 18-year-old freshman who comes into the college counseling center for some career counseling.
History
Darrel is a transfer student from China, living with a boarding family close to the college campus. He is an Advertising major at college. Darrel stated that he is unhappy at school. He didn’t know if he was unhappy with his major selection even though he couldn’t see himself doing anything else. Darrel described how recently he just doesn’t like anything he used to, including anything that has to do with Advertising. Darrel stated that his parent would be greatly disappointed if they knew that he was switching his major. He questioned why he had to do what they want anyway. The counselor suspected that the issues may be deeper than Darrel’s initial intake suggested. | null | In response to Darrel's sharing, the counselor should? | Deny feelings about counselor's own cultural identity | Encourage Darrel to assimilate to American culture | Focus on understanding Darrel's cultural view of the world | Tell Daniel that his feelings will soon pass | (A): Deny feelings about counselor's own cultural identity
(B): Encourage Darrel to assimilate to American culture
(C): Focus on understanding Darrel's cultural view of the world
(D): Tell Daniel that his feelings will soon pass | Focus on understanding Darrel's cultural view of the world | C | An effective counselor will develop an important skill of being able to see things from the client's perspective, including multicultural views. The counselor should not encourage Darrel to assimilate to American culture or dismiss his feelings of racial dissonance. The counselor should also be self-aware of her feelings about the topic and regarding her own cultural identity. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
622 | Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0) | Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f | You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it. | The client discusses how his case manager has gotten him into a shelter and is currently working on securing housing for him. The client processes feelings surrounding the shelter and has begun a detox program for his fentanyl addiction. The client verbalizes that he is experiencing anxiety surrounding being at meetings with the case manager, talking with other residents, reintegrating into a “more normal life,” and worrying about whether he can ever have a relationship with his kids or ex-wife if he gets sober. Through processing, you realize that this anxiety was present prior to drug use and that he has experienced anxiety throughout his life. During the session, the client states, “I don’t see how things will improve because things have been bad for so long | During the session, the client states, “I don’t see how things will improve because things have been bad for so long.” Which of the following best defines this type of cognitive distortion? | Minimizing | Catastrophizing | Black-and-white thinking | Generalization | (A): Minimizing
(B): Catastrophizing
(C): Black-and-white thinking
(D): Generalization | Generalization | D | Generalization involves taking a situation, such as the client’s recent history, and assuming that the future will be the same. Catastrophizing involves thinking the worst-case scenario will happen. Although the client thinks things will not improve, he isn’t focused on the worst-case scenario. Rather, he is experiencing hopelessness that things will ever be different. Black-and-white thinking means thinking things have to be either perfect or a complete failure. Although the client worries about things being the same, he is not focused on two extreme outcomes, but on the continuation of his situation. Minimizing is reducing the actual impact of a situation by not thinking about a situation as being as intense or severe as it actually is. Therefore, the correct answer is (D) | counseling skills and interventions |
623 | Client Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: University Counseling Center Type of Counseling: Individual and Group Presenting Problem: Interpersonal relationships Diagnosis: Autism Spectrum Disorder. 299.00 (F84.0) | Mental Status Exam: The client is sloppily dressed and appears his stated age. He exhibits pressured speech at times; otherwise, he speaks in a monotonous tone. The client becomes irritable when discussing the incident with campus police, and brightens when expressing his passion for snakes. He displays poor eye contact and there is difficulty with normal back-and-forth conversation. The client denies suicidal or homicidal ideation. He lives on campus in sober student housing and denies drug or alcohol use. History of th | You are a counselor a university counseling center. The university has a program providing limited assistance to students diagnosed with Autism Spectrum Disorder (ASD). The ASD program director has referred an 18-year-old white male enrolled in the program. She is concerned over his recent run-in with campus police. The client arrives to his scheduled counseling session today and explained that he has a girlfriend who “now apparently wants nothing to do with me.” Campus security has been involved due to the client showing up at his girlfriend’s dorm, yelling and creating a disturbance. The client explains that his peers told him he would have sex in college once he got a girlfriend. When his girlfriend refused to have sex, he said he didn’t understand and only wanted to talk. The client continues to express a desire to have sex now that he is in college by stating matter-of-factly, “I haven’t had much luck, but I’m going to keep trying.” When asked about interests, the client spoke at length about his love for snakes and knowledge of all 300 worldwide species. | The client arrives twenty minutes late for his appointment today. He explains that Mondays are the days he does laundry, and he cannot come again on a Monday. You review the required components of informed consent with the client. He expresses an understanding of the counseling process and provides written consent. The client states he has re-considered counseling because he believes you can help him find another girlfriend who will have sex with him. You tell him about a small group you run with other neurodiverse men, most of whom are on the autism spectrum. He expresses an interest in joining after hearing that sexual intimacy would be part of the curriculum. He provides a more solid commitment when you tell him the group is not held on Mondays. You arrive to your client’s group to find members on their cell phones sharing pictures of you and your family from your private social media account | You arrive to your client’s group to find members on their cell phones sharing pictures of you and your family from your private social media account. How should you respond? | Use it as a basis to explain the importance of group-specific parameters regarding confidentiality. | Use it to explain the benefits, limitations, and boundaries included in your social media policy. | Redirect the members to group tasks and personally seek technological knowledge and skills required for the ethical and legal use of social media. | Use it as a teachable moment to educate members on respecting the privacy of others. | (A): Use it as a basis to explain the importance of group-specific parameters regarding confidentiality.
(B): Use it to explain the benefits, limitations, and boundaries included in your social media policy.
(C): Redirect the members to group tasks and personally seek technological knowledge and skills required for the ethical and legal use of social media.
(D): Use it as a teachable moment to educate members on respecting the privacy of others. | Use it to explain the benefits, limitations, and boundaries included in your social media policy. | B | You should first use this as an opportunity to initiate a discussion or review your social media policy. According to the ACA Code of Ethics (2014), “Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media” Using the event to teach members to respect the privacy of others does not explicitly address social media use. Using the event as a basis for discussing group confidentiality, privacy, and violations is helpful, but this does not expressly address the use of social media. The ACA Code of Ethics (2014) states, “Counselors who engage in the use of distance counseling, technology, and/ or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (eg, special certifications, additional course work)” If counselors have a social media presence, they have an ethical and legal obligation to seek required technical knowledge and skills (eg, use privacy settings). However, the primary course of action must include informing group members of their use of social media as part of the ongoing process of informed consent. Additionally, the NBCC Code of Ethics (2016) states that “After carefully considering all of the ethical implications, including confidentiality, privacy, and multiple relationships, [counselors] shall develop written practice procedures in regard to social media and digital technology, and these shall be incorporated with the information provided to clients before or during the initial session”. Therefore, the correct answer is (D) | professional practice and ethics |
624 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | You meet with the client alone, and he appears to be more comfortable with you because he comes in and starts talking about a video game that he plays. You share that you have played that video game before. During the session, the client mentions that his parents got his first report card of the year and found out that he was failing most of his classes. He started to say that he was worried that his dad was going to hit him because of his grades. You ask if his father hits him often, and he replies that he does several times a week. You try to inquire about the manner of hitting his father uses because a certain level of corporal punishment is legal in the state that you work in. The client says that he is not going to talk any more about this. You remind the client that you likely will need to report this to child protective services and he says, “I don’t care” in response. You spend the rest of this session processing his relationship with his parents, and he discloses that he does love them, but that they are not his real parents. You meet with the client’s parents near the end of the session, and, while talking with them, they report that he was neglected while in foster care because the foster parent was “just in it for the money | Based on the client’s report that his father hits him several times each week, which would be the next step based on best practice? | Assess to determine if the abuse allegations are credible before reporting them to the relevant authorities. | Continue to check in with the client during the next few sessions to determine if you can gather more substantial information before reporting any abuse to the relevant authorities. | Gather the necessary information and report it to the relevant authorities regardless of whether or not the allegations seem credible. | Request that the parents join the session to further process the allegations and determine their credibility. | (A): Assess to determine if the abuse allegations are credible before reporting them to the relevant authorities.
(B): Continue to check in with the client during the next few sessions to determine if you can gather more substantial information before reporting any abuse to the relevant authorities.
(C): Gather the necessary information and report it to the relevant authorities regardless of whether or not the allegations seem credible.
(D): Request that the parents join the session to further process the allegations and determine their credibility. | Gather the necessary information and report it to the relevant authorities regardless of whether or not the allegations seem credible. | C | Your obligation as a mandated reporter is to report allegations of abuse, neglect, or exploitation of minors, regardless of whether you think they are credible or not. It is the local government agency’s responsibility to assess and determine if allegations are founded. Do not wait too long after the abuse to report it for several reasons. Your state may have laws on the time frame to report (eg, some states require that you report allegations within 24 hours of the report), and the client may in fact be at risk of further harm from his father if the allegations are true. Bringing the parents into the session can be helpful in certain circumstances, but it is important to consider if this may cause more harm to your client because the father may retaliate toward him. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
625 | Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00) | Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam | You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her. | ily and Work History: The client was married for 15 years before she divorced. She and her ex-husband share custody of their 16-year-old son. The client is an only child and reports that her parents were strict and overbearing when she was growing up. She works as a travel photographer and, until recently, worked for a large national publication. She enjoyed her job but cannot envision a time when she would feel comfortable staying in hotels again. This fear has prevented her from exploring other travel accommodations while on assignment. She states, “There are too many unknowns with travel, and I just don’t think I can do it any longer.” The client’s insurance company is requesting a level-of-care assessment | The client’s insurance company is requesting a level-of-care assessment. In behavioral health settings, which of the following would best help with this determination? | Treatment summary | Diagnosis | Medical necessity | Payor source | (A): Treatment summary
(B): Diagnosis
(C): Medical necessity
(D): Payor source | Medical necessity | C | Insurance providers require clinicians to establish medical necessity when determining a client’s appropriate level of care. Services must be medically necessary to receive provider reimbursement, including approval for the frequency, length, and duration of clinical services. Medical necessity determines preapproval and ongoing approval for authorized services. Medical necessity, service utilization, and functional impairment are considered when assigning a client’s level of care. The level of care is used when determining the least restrictive setting for a client’s treatment, with lower levels of care assigned to those receiving outpatient services and a higher level of care required for more restrictive settings (eg, hospitalization to residential treatment). Diagnosis is a level-of-care consideration, but the diagnosis alone does not reflect functional impairment and the client’s level of distress. In general, treatment summaries are insufficient for determining the level of care. A payor source refers to an individual or entity responsible for charges generated from treatment services. Payor sources request level of care assessments; they do not provide clinical assessment. Therefore, the correct answer is (A) | professional practice and ethics |
626 | Client Age: Client 1: Age 18 Client 2: Age 21 Client 3: Age 22 Client 4: Age 19 Client 5: Age 18 Sex: Male and female Gender: Male and female Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: All members are single Counseling Setting: Counseling clinicType of Counseling: Group and individual counseling Presenting Problem: All individuals are seeking support for struggles related to borderline personality disorder. Diagnosis: Borderline personality disorder (F60.3) | Mental Status Exam: All clients appear to be oriented to time, situation, location, and person. The clients are all dressed appropriately for the weather. No clients appear to experience any visual or auditory hallucinations. Most of the clients are presenting as friendly but gua | You are a licensed therapist running a dialectical behavior therapy (DBT) group for young adults. You also provide a weekly individual counseling session for each group member, which is common practice for DBT group therapy. During the first session, you provide psychoeducation on DBT and the group process. Most of the members seem closed off and sometimes aggressive in response to being asked to speak during the first session, which can be consistent with borderline personality disorder. Client 3 becomes upset about halfway through the session, stating that he does not need to participate because the group will eventually end, so he does not need to build relationships with the group members. You end the session by planning individual therapy sessions with each group member. | You meet with client 3 for his individual therapy session. The client continues to be resistant, stating that he does not need to meet with you. You spend the session trying to build rapport with the client and are successful in taking down some of his walls. The client says he knew client 2 from back when he was in high school and began telling you that she slept with a bunch of guys and did a lot of drugs. You redirect the client back to focusing on himself. The client starts to open up about his relationship with his parents growing up and how he thinks they did not really try to show him affection and this made him sad talking about it. The client concludes by saying “I feel overwhelmed sharing all of this because I’ve never talked about it before.” You thank the client for sharing and you empathize with him | Which of the following statements demonstrates the use of empathy regarding the client’s disclosure about his relationship with his parents? | “I’m sorry to hear that you had little affection from your parents, but I’m proud of you for talking about it now even though it’s hard.” | “Correct me if I’m wrong, but it sounds like you didn’t feel a connection with your parents growing up and this is hard to talk about.” | “I can imagine that it’s hard to talk about something so personal and that it would be sad to not be close with your parents.” | “It sounds like talking about this is difficult for you.” | (A): “I’m sorry to hear that you had little affection from your parents, but I’m proud of you for talking about it now even though it’s hard.”
(B): “Correct me if I’m wrong, but it sounds like you didn’t feel a connection with your parents growing up and this is hard to talk about.”
(C): “I can imagine that it’s hard to talk about something so personal and that it would be sad to not be close with your parents.”
(D): “It sounds like talking about this is difficult for you.” | “I can imagine that it’s hard to talk about something so personal and that it would be sad to not be close with your parents.” | C | The use of the wordimagineand attempting to connect with the client’s situation would best demonstrate empathy. Empathy is focused on connecting and relating to the emotions expressed by the client and demonstrating your understanding to the client. Expressing sorrow with the client demonstrates an expression of sympathy because it is a reaction to someone else’s distress. The response stating that it sounds like talking about the topic is difficult is an example of paraphrasing because it identifies the client’s feeling and restates it. The statement stating that it sounds like the client did not feel much of a connection with his parents and acknowledging that it must be hard to talk about this topic is an example of summarization because it identifies the major elements of what was shared by the client. Therefore, the correct answer is (D) | counseling skills and interventions |
627 | Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility | The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor. | First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. | The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father. | When forming your treatment plan for the couple, how do your observations from the mental status exam inform your approach? | Focus on improving the couple's emotional connection and trust | Focus on the wife's lack of assertiveness skills and explore ways for her to gain more independence | Focus on the son's treatment for Autism. | Focus on their communication issues, and incorporate cognitive-behavioral techniques to address them. | (A): Focus on improving the couple's emotional connection and trust
(B): Focus on the wife's lack of assertiveness skills and explore ways for her to gain more independence
(C): Focus on the son's treatment for Autism.
(D): Focus on their communication issues, and incorporate cognitive-behavioral techniques to address them. | Focus on improving the couple's emotional connection and trust | A | During the MSE, your observations indicate that the couple is experiencing a lack of trust between them - they are sitting far apart from each other and refusing to look at each other. Exploring the trust issues between the husband and wife would be the most effective approach when creating a treatment plan for this couple. Therefore, the correct answer is (A) | treatment planning |
628 | Name: Candy Clinical Issues: Anxiety and relationship distress Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.03 Borderline Personality Disorder Age: 29 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client presented as a well-groomed female who appeared her stated age. She was appropriately dressed in casual attire. Her speech was marked by a slow rate and low volume overall, though, at times, her rate and loudness increased spontaneously. Her tone was muffled and difficult to hear clearly at times. The client's mood appeared depressed and confused. She displayed emotional lability during the evaluation, with shifts between expressing elation, fear, and distrust of this clinician and the treatment environment. Despite her affective instability, she was oriented to person, place, and time. Her attention and concentration waxed and waned throughout the session, with some difficulty tracking questions and sustaining focus on topics. She denied current homicidal ideation or intent. However, the client endorsed chronic passive suicidal ideation that intensifies during times of high personal stress. She also reported a remote history of hospitalization due to engaging in self-injurious cutting behaviors when feeling extremely distressed. | First session You are a clinical mental health counselor working in a private practice setting. The client, a 29-year-old female, presents to the intake session expressing that she has trouble controlling impulsive acts and is constantly worried. She speaks about her marriage, describing it as up and down. She looks down tearfully and says, "I keep hurting him. One day I love him, and the next day I can't look at him." She pauses and asks, "What if he leaves me? I can't deal with that." She further reveals that after she fights with her husband, she goes into their bedroom and cuts her thighs. At first, she feels relief, but this is followed by profound sadness and a feeling of worthlessness. The client's lack of a stable parental figure resulted in her having difficulty forming healthy attachments with others. She feels isolated and disconnected from the world around her and has difficulty appropriately expressing her emotions. Her relationships are often strained, and she finds it difficult to trust others or herself. She has difficulty setting healthy boundaries and repeatedly emotionally abuses herself and others. She reports feeling overwhelmed by her emotions and finds it difficult to regulate them. She states that she experiences intense guilt and shame following her impulsive acts and is often worried that her husband may leave her due to her behaviors. The client has struggled to control her emotions, which has been a source of significant distress in her life. The client's self-destructive behavior has become increasingly frequent and intense. She has been unable to find a way to cope with her emotions and has resorted to self-harm as a way to manage her distress. She has become increasingly isolated and withdrawn, and her relationships have suffered as a result. She has become increasingly dependent on her husband, and her fear of abandonment has become a source of significant distress. Third session You are in your office waiting for the client to arrive for her weekly session when suddenly you hear screaming. You run out into the hallway and see the client crying hysterically. After guiding her into your office, she lies on the couch, crying. She begins to punch the pillows on the sofa. You indicate you are here to listen when she is ready to talk. The client is in a heightened emotional state and says, "He. Left. Me." You maintain a calm demeanor and encourage the client to tell you what happened. She said she arrived home after work and noticed her husband's car was gone. He had left her a note indicating he was leaving and wanted a divorce. The client expresses feelings of shock and betrayal as she discusses how she had been blindsided by her husband's sudden decision to end the marriage. She reports feeling overwhelmed by a range of emotions, including fear, anger, sadness, and confusion. The client expresses hopelessness and despair, believing her situation is beyond repair. She ruminates on the idea that her marriage is irrevocably broken and that her life will never be the same. She expresses feelings of helplessness and fear of the unknown, feeling overwhelmed by the magnitude of the situation. The client struggles to make sense of her husband's decision and appears overwhelmed by the potential consequences. She is particularly concerned about how her husband's decision will affect their children and their family's future. The client stares at you with a blank expression and states, "I might as well give up. There's no point anymore." You further assess her current mental health state and determine that she is suffering from an acute stress reaction. You provide empathy and validation while creating a safe space for the client to process her thoughts and feelings. You encourage her to talk openly and honestly about her experience, allowing her to express her emotions without judgment. | The client's father died when she was very young. She describes her mother as having a "difficult time raising me and my brother as a single mother." The client's mother worked three jobs and could not spend much time with her children. The client remembers having several babysitters as a child, but they never lasted long. Currently, the only relative the client speaks with is her mother. She lists her husband and mother as her emergency contacts on the intake form. The client reports feeling isolated and alone, especially since her father's death. Personal/Social Relationships: The client has a long history of attempting suicide. She has been in and out of emergency rooms nearly every week. She is persistently angry, needs attention and recognition, and has difficulty trusting others. She has had numerous affairs in an attempt to feel worthy. The client compensates for her guilt by buying her husband expensive gifts. She grapples with maintaining healthy relationships and controlling her rage and violent behaviors when she feels threatened. She has struggled to form meaningful relationships with her peers and has few friends. Although she does not lack socialization skills, the client finds it difficult to get close to people. Previous Counseling: The client is currently taking Paxil for her underlying depressive symptoms. She has expressed concern about her ability to manage her mental health with her current treatment. She worries that her erratic adherence to her medication regimen and lack of follow-up with her psychiatrist could lead to a termination of services. She has reported increased anxiety and stress as a result of this fear. She reports that her mood swings are more extreme, and she is having difficulty concentrating and staying focused. She reports that her friends and family have noticed her behavior change and expressed concern. | What is the best response to the client's statement about giving up? | "It sounds like you're feeling overwhelmed and discouraged, but it's important to remember that you can make it through this difficult time. Let's examine your options." | "It sounds like you're feeling overwhelmed and discouraged. Have you tried talking to your husband about why he left?" | "It sounds like you're feeling down and deciding what course of action to take to move forward. Have you considered talking to an attorney?" | "It's understandable that you're feeling overwhelmed and discouraged. How can I help you feel better right now?" | (A): "It sounds like you're feeling overwhelmed and discouraged, but it's important to remember that you can make it through this difficult time. Let's examine your options."
(B): "It sounds like you're feeling overwhelmed and discouraged. Have you tried talking to your husband about why he left?"
(C): "It sounds like you're feeling down and deciding what course of action to take to move forward. Have you considered talking to an attorney?"
(D): "It's understandable that you're feeling overwhelmed and discouraged. How can I help you feel better right now?" | "It sounds like you're feeling overwhelmed and discouraged, but it's important to remember that you can make it through this difficult time. Let's examine your options." | A | This response acknowledges the client's feelings while providing reassurance and hope. It helps to reframe the client's experience and delivers a supportive and encouraging message. It also helps give a sense of direction and encourages the client to take small steps to help on the journey toward self-improvement. Through this response, it is possible to build trust and rapport with the client and open up meaningful conversations. Therefore, the correct answer is (B) | counseling skills and interventions |
629 | Client Age: 15 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: African American Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Anxiety Diagnosis: Generalized Anxiety Disorder (GAD) 300.02 (F41.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is neat in appearance. She is cooperative and, at times, overly compliant with the interview questions, which is exemplified by apologizing unnecessarily for “not answering questions in the right way.” Her eye contact is poor, but she is engaged in the interview process. The client is restless and fidgety, and her tone of voice is soft. She states that she gets between 5 and 6 hours of sleep each night, which makes her irritable at times. Her affect is anxious, and she reports poor concentration. Her excessive worry has resulted in exhaustion and feeling like she is “always playing catch-up” with sleep and schoolwork. She denies any suicidal or homicidal ideations. The client also denies drug or alcohol use. Family History and History of th | You are a counselor working in a child and family outpatient mental health center. Your client is a 15-year-old African American female enrolled in the 10th grade at a predominately white private high school. She presents today with her father, who says she “has not been herself lately.” The client reports that she is under an enormous amount of pressure to excel academically and athletically. She is the number-one ranked player on the varsity tennis team and is in the school’s honors program. The client states that she perseverates the night before a tennis match and worries that her performance will be subpar. She reports excessively practicing her serves and backhands in her spare time because she is constantly dissatisfied with her less-than-perfect performance. The client says that she feels like she doesn’t fit in with her peers, which she attributes to being the only person of color on her tennis team, and one of few in the student body. | e The client’s milestones for walking, talking, and toilet training were all developmentally appropriate. The client is the only child of parents who divorced when the client was 5 years old. She states that she has always been a worrier and remembers seeing the school counselor in kindergarten for separation anxiety. Her father has physical custody of the client, and her mother sees the client at regular visitation intervals. The father is a tennis pro, and her mother works as a fitness trainer. The client describes her parents as “type A” and explains, “They are always pushing me to my limit.” The client’s mother has panic attacks, which the client believes are manageable with medication. Her maternal grandmother was an alcoholic who died when her mother was younger. There are no reported mental health issues on the paternal side of the family | For adolescents, hypothesized psychological vulnerabilities for GAD include which of the following? | Sleep irregularity | Cognitive biases | Autonomic hyperreactivity | Positive valence systems | (A): Sleep irregularity
(B): Cognitive biases
(C): Autonomic hyperreactivity
(D): Positive valence systems | Cognitive biases | B | Hypothesized psychological vulnerabilities for GAD include cognitive biases. Counselors assess clients for vulnerabilities to help identify specific factors that may predispose someone to certain psychological disorders. Psychological vulnerabilities for GAD include cognitive biases, insecure attachment, unstable affect management, and unconscious conflicts. Biological vulnerabilities include sleep irregularities and autonomic hyperactivity, which is a physiological component of GAD and includes physiological symptoms such as dry mouth, heart palpitations, and sweating. Negative rather than positive valence systems are associated with GAD. Negative valence includes affective states such as anxiety and depression, whereas positive valence includes happiness and joy. Social vulnerabilities, such as trauma, certain parenting styles, and peer rejection, are also associated with GAD development. Therefore, the correct answer is (D) | professional practice and ethics |
630 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express | You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex. | Diagnosis: Premature Ejaculation, Acquired, Generalized, Mild (F52.4) ions. Family History: The client reports that he has been in a relationship with his girlfriend for 3 years. The client says that he is close with his parents and his younger brother. You suspect that the client also has generalized anxiety disorder | You suspect that the client also has generalized anxiety disorder. All of the following would confirm this diagnosis EXCEPT: | Fear of panic attacks | Having trouble falling asleep | Excessive anxiety experienced on more days than not for 6 months | Being easily fatigued | (A): Fear of panic attacks
(B): Having trouble falling asleep
(C): Excessive anxiety experienced on more days than not for 6 months
(D): Being easily fatigued | Fear of panic attacks | A | The fear of panic attacks meets the criteria for panic disorder, but it is not part of the required criteria for generalized anxiety disorder. Excessive anxiety that is present for more than 6 months, being easily fatigued, and trouble falling asleep are all criteria for generalized anxiety disorder. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
631 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | Mary's daughter Evelyn calls to speak with you, and you answer the call because it is an unknown number and could be a potential new client. She identifies herself and asks you how her mother is doing in therapy, adding that her mother has been avoiding her calls. How should you respond? | "Let me ask her to sign a release of information and then we can talk." | "Can you tell me more about your observations of her behaviors?" | "I'm sorry, Ms. Evelyn, I cannot confirm or deny information about a client." | "Oh hi! Your mother is doing her best, I believe. She'll get there." | (A): "Let me ask her to sign a release of information and then we can talk."
(B): "Can you tell me more about your observations of her behaviors?"
(C): "I'm sorry, Ms. Evelyn, I cannot confirm or deny information about a client."
(D): "Oh hi! Your mother is doing her best, I believe. She'll get there." | "I'm sorry, Ms. Evelyn, I cannot confirm or deny information about a client." | C | Counselors are bound by HIPAA confidentiality laws to maintain client confidentiality unless they already have specific, written consent to speak with another person about their care or are responding out of attempt to help a client who is in grave danger. Even confirming you have a client in your care is breaking confidentiality, which is why answer b) is incorrect. Once obtaining a signed release of information, you may contact the family member back and discuss whatever was permitted on the consent form. In this case, the scenario does not indicate that Mary signed consent for anyone. Therefore, the correct answer is (C) | professional practice and ethics |
632 | Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual | Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings. | Diagnosis: Acute Stress Reaction (F43.0), Provisional
You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established. | Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father. | Noting Maria's resistance and sensitivity, how should you proceed? | Challenge her to focus on her own feelings. | Listen attentively and empathize. | Have her complete the Trauma-Informed Self-Assessment Tool. | Point out your observation. | (A): Challenge her to focus on her own feelings.
(B): Listen attentively and empathize.
(C): Have her complete the Trauma-Informed Self-Assessment Tool.
(D): Point out your observation. | Listen attentively and empathize. | B | Answers a) or c) may stop the flow of her openly sharing since she has already made clear she does not want to admit to her own feelings. Pointing out your observation or insisting she focus on herself may cause her to resist further. The Trauma-Informed Self-Assessment Tool is designed to help organizations identify how to improve their programming by making it more trauma-informed. The best way to help Maria continue to share freely is to just apply active listening skills as you would if she were sharing about herself. Therefore, the correct answer is (B) | core counseling attributes |
633 | Name: Candy Clinical Issues: Anxiety and relationship distress Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.03 Borderline Personality Disorder Age: 29 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client presented as a well-groomed female who appeared her stated age. She was appropriately dressed in casual attire. Her speech was marked by a slow rate and low volume overall, though, at times, her rate and loudness increased spontaneously. Her tone was muffled and difficult to hear clearly at times. The client's mood appeared depressed and confused. She displayed emotional lability during the evaluation, with shifts between expressing elation, fear, and distrust of this clinician and the treatment environment. Despite her affective instability, she was oriented to person, place, and time. Her attention and concentration waxed and waned throughout the session, with some difficulty tracking questions and sustaining focus on topics. She denied current homicidal ideation or intent. However, the client endorsed chronic passive suicidal ideation that intensifies during times of high personal stress. She also reported a remote history of hospitalization due to engaging in self-injurious cutting behaviors when feeling extremely distressed. | First session You are a clinical mental health counselor working in a private practice setting. The client, a 29-year-old female, presents to the intake session expressing that she has trouble controlling impulsive acts and is constantly worried. She speaks about her marriage, describing it as up and down. She looks down tearfully and says, "I keep hurting him. One day I love him, and the next day I can't look at him." She pauses and asks, "What if he leaves me? I can't deal with that." She further reveals that after she fights with her husband, she goes into their bedroom and cuts her thighs. At first, she feels relief, but this is followed by profound sadness and a feeling of worthlessness. The client's lack of a stable parental figure resulted in her having difficulty forming healthy attachments with others. She feels isolated and disconnected from the world around her and has difficulty appropriately expressing her emotions. Her relationships are often strained, and she finds it difficult to trust others or herself. She has difficulty setting healthy boundaries and repeatedly emotionally abuses herself and others. She reports feeling overwhelmed by her emotions and finds it difficult to regulate them. She states that she experiences intense guilt and shame following her impulsive acts and is often worried that her husband may leave her due to her behaviors. The client has struggled to control her emotions, which has been a source of significant distress in her life. The client's self-destructive behavior has become increasingly frequent and intense. She has been unable to find a way to cope with her emotions and has resorted to self-harm as a way to manage her distress. She has become increasingly isolated and withdrawn, and her relationships have suffered as a result. She has become increasingly dependent on her husband, and her fear of abandonment has become a source of significant distress. Third session You are in your office waiting for the client to arrive for her weekly session when suddenly you hear screaming. You run out into the hallway and see the client crying hysterically. After guiding her into your office, she lies on the couch, crying. She begins to punch the pillows on the sofa. You indicate you are here to listen when she is ready to talk. The client is in a heightened emotional state and says, "He. Left. Me." You maintain a calm demeanor and encourage the client to tell you what happened. She said she arrived home after work and noticed her husband's car was gone. He had left her a note indicating he was leaving and wanted a divorce. The client expresses feelings of shock and betrayal as she discusses how she had been blindsided by her husband's sudden decision to end the marriage. She reports feeling overwhelmed by a range of emotions, including fear, anger, sadness, and confusion. The client expresses hopelessness and despair, believing her situation is beyond repair. She ruminates on the idea that her marriage is irrevocably broken and that her life will never be the same. She expresses feelings of helplessness and fear of the unknown, feeling overwhelmed by the magnitude of the situation. The client struggles to make sense of her husband's decision and appears overwhelmed by the potential consequences. She is particularly concerned about how her husband's decision will affect their children and their family's future. The client stares at you with a blank expression and states, "I might as well give up. There's no point anymore." You further assess her current mental health state and determine that she is suffering from an acute stress reaction. You provide empathy and validation while creating a safe space for the client to process her thoughts and feelings. You encourage her to talk openly and honestly about her experience, allowing her to express her emotions without judgment. | The client's father died when she was very young. She describes her mother as having a "difficult time raising me and my brother as a single mother." The client's mother worked three jobs and could not spend much time with her children. The client remembers having several babysitters as a child, but they never lasted long. Currently, the only relative the client speaks with is her mother. She lists her husband and mother as her emergency contacts on the intake form. The client reports feeling isolated and alone, especially since her father's death. Personal/Social Relationships: The client has a long history of attempting suicide. She has been in and out of emergency rooms nearly every week. She is persistently angry, needs attention and recognition, and has difficulty trusting others. She has had numerous affairs in an attempt to feel worthy. The client compensates for her guilt by buying her husband expensive gifts. She grapples with maintaining healthy relationships and controlling her rage and violent behaviors when she feels threatened. She has struggled to form meaningful relationships with her peers and has few friends. Although she does not lack socialization skills, the client finds it difficult to get close to people. Previous Counseling: The client is currently taking Paxil for her underlying depressive symptoms. She has expressed concern about her ability to manage her mental health with her current treatment. She worries that her erratic adherence to her medication regimen and lack of follow-up with her psychiatrist could lead to a termination of services. She has reported increased anxiety and stress as a result of this fear. She reports that her mood swings are more extreme, and she is having difficulty concentrating and staying focused. She reports that her friends and family have noticed her behavior change and expressed concern. | When would it be most effective for you to use the skill of summarization with this client? | When you want to demonstrate to the client that you understand what she has said and what she is feeling | When the client is emotive and needs to be grounded on a cognitive level | When you want to outline the main themes that are emerging in the session | When you want to clarify what the client is feeling | (A): When you want to demonstrate to the client that you understand what she has said and what she is feeling
(B): When the client is emotive and needs to be grounded on a cognitive level
(C): When you want to outline the main themes that are emerging in the session
(D): When you want to clarify what the client is feeling | When you want to outline the main themes that are emerging in the session | C | When using the summarization skill, the therapist shares the main emerging points in the session. This allows the client to correct the therapist if she feels or sees things differently. Summarizing can also help structure sessions when the client has difficulty focusing on topics and objectives. Therefore, the correct answer is (D) | counseling skills and interventions |
634 | Name: Christopher Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency | The client presents partially as her preferred gender, wearing makeup and a semi-long hairstyle while still dressed as a cis-gendered 12-year-old male. She reports feelings of depression, anger, and suicidal ideation without a plan or intent. She appears to be her stated age, cooperates during the interview, and maintains good eye contact. Speech is normal in rate, rhythm, and volume. The client's thought processes are organized and goal-directed. She is alert and oriented X2. Insight and judgment are fair. | First session A 13-year-old, assigned male at birth and identifying as female, arrives at your office in a community mental health agency where you work as a mental health therapist. Both parents are also in attendance. The client introduces herself to you as "Christine," although the father says "Christopher" each time he addresses the client. The client appears dejected every time her father misgenders her. The client reports experiencing bullying from male peers at school and is upset that her father refuses to use her chosen pronouns or name. The client reports that she has been feeling increasingly isolated and hopeless since the start of her transition, leading to intrusive thoughts associated with suicide. She is trying to express her identity through clothing, hair, and physical appearance but is not allowed to do so by her father. The client's mother is somewhat more supportive of her transition and has been trying to advocate for her, but her father remains resistant to the idea and is often dismissive of her identity. The client expressed feeling frustrated and helpless in her home life, as she cannot express her gender identity freely. Once the client's parents leave the room, the client reports wanting to kill herself and tells you about the depression that sets in after being bullied at school or after arguments with her father. She also holds a lot of anger toward her father. Toward the end of the initial counseling session, the client says she feels safe with you and "would like to work together." | The client loves her mother but has difficulties with her father. Her parents differ in child-rearing styles, with her father not understanding her gender presentation. The client has a deep-seated fear of rejection and abandonment from her father due to the ongoing disagreement about her gender presentation. She feels that her father does not accept her for who she is and does not understand her identity. The client has a strong need for her father's acceptance and approval, but her attempts to bridge the gap between them have been unsuccessful. This has caused her to feel disconnected from her father and has created a sense of sadness and insecurity in the client. Neither parent supports her gender choice, but her father actively confronts her daily. Her mother is confused and worried for the client but does not know what to do. The client is high achieving academically and is well-liked by her teachers. In addition, she is involved in a community dance team where she excels. However, she is socially isolated and has few friends. Her classmates mock her for "acting like a girl" and bully her on the playground. She is especially bullied by her male peers in school. The client is displaying symptoms of social anxiety as she has difficulty developing and maintaining relationships with her peers. Her fear of being ridiculed and judged by her peers has resulted in her feeling socially isolated, impacting her self-esteem. The client is anxious in social situations, particularly when interacting with her male peers, and displays a pattern of avoiding social interactions due to the fear of being judged. | What would you address first in your initial treatment plan? | The client's intense feelings regarding her inability to function within societal norms regarding gender presentation | Your experience in working with clients who have gender dysphoria | The client's thoughts of harming herself | The father's intransigence regarding his ways of expressing his displeasure regarding his child's expressed gender identity | (A): The client's intense feelings regarding her inability to function within societal norms regarding gender presentation
(B): Your experience in working with clients who have gender dysphoria
(C): The client's thoughts of harming herself
(D): The father's intransigence regarding his ways of expressing his displeasure regarding his child's expressed gender identity | The client's thoughts of harming herself | C | Safety is the primary issue in this case with the client's verbal threats of suicide and self-report of depression. Therefore, the correct answer is (A) | treatment planning |
635 | Name: Christopher Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency | The client presents partially as her preferred gender, wearing makeup and a semi-long hairstyle while still dressed as a cis-gendered 12-year-old male. She reports feelings of depression, anger, and suicidal ideation without a plan or intent. She appears to be her stated age, cooperates during the interview, and maintains good eye contact. Speech is normal in rate, rhythm, and volume. The client's thought processes are organized and goal-directed. She is alert and oriented X2. Insight and judgment are fair. | First session A 13-year-old, assigned male at birth and identifying as female, arrives at your office in a community mental health agency where you work as a mental health therapist. Both parents are also in attendance. The client introduces herself to you as "Christine," although the father says "Christopher" each time he addresses the client. The client appears dejected every time her father misgenders her. The client reports experiencing bullying from male peers at school and is upset that her father refuses to use her chosen pronouns or name. The client reports that she has been feeling increasingly isolated and hopeless since the start of her transition, leading to intrusive thoughts associated with suicide. She is trying to express her identity through clothing, hair, and physical appearance but is not allowed to do so by her father. The client's mother is somewhat more supportive of her transition and has been trying to advocate for her, but her father remains resistant to the idea and is often dismissive of her identity. The client expressed feeling frustrated and helpless in her home life, as she cannot express her gender identity freely. Once the client's parents leave the room, the client reports wanting to kill herself and tells you about the depression that sets in after being bullied at school or after arguments with her father. She also holds a lot of anger toward her father. Toward the end of the initial counseling session, the client says she feels safe with you and "would like to work together." | The client loves her mother but has difficulties with her father. Her parents differ in child-rearing styles, with her father not understanding her gender presentation. The client has a deep-seated fear of rejection and abandonment from her father due to the ongoing disagreement about her gender presentation. She feels that her father does not accept her for who she is and does not understand her identity. The client has a strong need for her father's acceptance and approval, but her attempts to bridge the gap between them have been unsuccessful. This has caused her to feel disconnected from her father and has created a sense of sadness and insecurity in the client. Neither parent supports her gender choice, but her father actively confronts her daily. Her mother is confused and worried for the client but does not know what to do. The client is high achieving academically and is well-liked by her teachers. In addition, she is involved in a community dance team where she excels. However, she is socially isolated and has few friends. Her classmates mock her for "acting like a girl" and bully her on the playground. She is especially bullied by her male peers in school. The client is displaying symptoms of social anxiety as she has difficulty developing and maintaining relationships with her peers. Her fear of being ridiculed and judged by her peers has resulted in her feeling socially isolated, impacting her self-esteem. The client is anxious in social situations, particularly when interacting with her male peers, and displays a pattern of avoiding social interactions due to the fear of being judged. | After disclosing suicidal ideation, the client asks if you have to inform her parents. At which point in the therapy process do you go over this information? | During individual sessions with the parents | Immediately after the client discloses suicidal ideation | During the intake session | At the time of the pre-admission process of setting up sessions. | (A): During individual sessions with the parents
(B): Immediately after the client discloses suicidal ideation
(C): During the intake session
(D): At the time of the pre-admission process of setting up sessions. | During the intake session | C | Information about the limits of confidentiality should be provided to the client and parents during the intake session. No mental health services should be provided until after the client has completed this process. Therefore, the correct answer is (B) | professional practice and ethics |
636 | Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice | The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor. | First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me." Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me." His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities. You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | Using Gestalt therapy, which technique would be most appropriate for the client to explore interpersonal conflict? | Reversal technique | Empty chair | Internal dialogue exercise | Staying with the feeling | (A): Reversal technique
(B): Empty chair
(C): Internal dialogue exercise
(D): Staying with the feeling | Internal dialogue exercise | C | The internal dialogue exercise involves asking the client to imagine they are having a conversation with themselves, or another person, in which they can express their feelings and perspectives freely and openly without fear of judgment or criticism. By exploring these feelings and perspectives internally, the client can gain insight into their thoughts and behaviors that may be causing distress. In the client's case, this technique could help him identify and work through his feelings towards his family in a productive way. Through the internal dialogue exercise, the client can gain insight into why he feels the need to act out or become aggressive when expressing his anger and resentment towards his family. Therefore, the correct answer is (C) | counseling skills and interventions |
637 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | The couple comes into the session and sits down. Their body language does not appear as uncomfortable as it has in previous sessions because they are sitting a little closer together. You ask both individuals what they need to work on. The wife says that she knows that she needs to rebuild trust, and the husband says that he wants to know more about what happened in the affair before they move forward. The couple report that they tried to engage in sex, but that the husband stopped during intercourse. The husband states that he could not get the idea out of his mind that his wife does not find him attractive because she was with a woman. You ask the husband what it means for their marriage if his wife does not find him attractive, and he states that it means he will not be able to please her. You then ask him what it means for the relationship if he cannot please her, and he responds that it means he cannot be a good husband. You follow up asking what it means if he cannot be a good husband, and he says that they will have a miserable marriage. You support effective communication strategies and empathize with the couple. After the session, the wife comes back to get her coffee that she left and says that she knows that she hurt her husband and is in the wrong, so she will do whatever her husband needs to rebuild trust. At one point during the session, the husband stops talking completely | At one point during the session, the husband stops talking completely. Which one of the following actions is the most effective way to deal with this example of stonewalling? | Encourage the couple to support each other in coping with strong emotions and then help them process how they are feeling. | Instruct the client to walk away without saying something that would escalate the situation. | Instruct the client to express that he is overwhelmed and to request a break. | Encourage the couple to discuss how they are feeling and address their presenting emotions and thoughts. | (A): Encourage the couple to support each other in coping with strong emotions and then help them process how they are feeling.
(B): Instruct the client to walk away without saying something that would escalate the situation.
(C): Instruct the client to express that he is overwhelmed and to request a break.
(D): Encourage the couple to discuss how they are feeling and address their presenting emotions and thoughts. | Instruct the client to express that he is overwhelmed and to request a break. | C | According to Dr John Gottman’s four negative behaviors, or the “Four Horsemen of the Apocalypse,” there are four characteristics of communication within a couple that increase the risk for divorce: stonewalling, contempt, criticism, and defensiveness. The most effective way to manage stonewalling, according to Gottman, is for the client to express that he is overwhelmed and to request a break. Walking away without saying anything would reinforce the stonewalling and would likely escalate the situation. A discussion with the couple or encouragement in coping with strong emotions together may lead to further escalation due to the gravity and rawness of the husband’s emotions and would not support him in managing these strong emotions. Therefore, the correct answer is (A) | counseling skills and interventions |
638 | Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry. | First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week. Fourth session The client has been seeing you every Tuesday and likes to schedule his weekly appointments a month in advance. Last week, you asked him to bring in a list of the triggers for his anger and the strategies he has tried in the past to manage it. You explained that this would help you create an individualized treatment plan with specific goals and objectives to work on throughout therapy. Furthermore, you suggested coming up with potential coping strategies to employ if/when he finds himself in a situation in which he feels the need to withdraw or avoid. You also stressed the importance of identifying and addressing any underlying issues contributing to this behavior. Today, you spend the session exploring his anger and constant road rage, and you help him identify his feelings. He recognizes that the rage comes from a sense of being disrespected and feeling taken advantage of. As you continue that discussion, the client has a revelation. He recognizes that he also feels insignificant, unappreciated, and taken advantage of by his adult children. He wonders aloud if they like him. You focus on providing a positive therapeutic empathic response to meet his need to connect in relationships. Seventh session The client was a "no show" for his session last week. You did not hear from him and ended up reaching out to him to reschedule. He arrives at this session on time and is eager to talk about a situation that occurred with his daughter. He had reached out to her to talk about repairing the relationship, and after some convincing, she had agreed. She came to pick him up to go for lunch, and while they were in a car together, he used a term that is now considered politically incorrect to refer to one of her friends. His daughter got upset with him and would not speak with him any further. He attempted to defend himself by saying that the term he used was not derogatory. He presents this as "yet another example" of his children not liking him, and "never giving him a chance". He does not know how to move forward. He tells you that he "can't do anything right" and is a failure where his children are concerned. He mentions that this episode was especially frustrating, because he has so happy at arranging this meeting. You disclose your own frustration with one of your family members and explain that sometimes that person only seems interested in connecting with you when they need help. You also incorporate a strengths-based approach to build the client's resilience. | null | What is the best way to address the client's "no show" to his previously scheduled session? | Remind the client about your cancellation policy | Submit an invoice to the client for the "no show" | Engage the client concerning the deeper motivation behind his absence. | Overlook the "no show" and move on to the next session | (A): Remind the client about your cancellation policy
(B): Submit an invoice to the client for the "no show"
(C): Engage the client concerning the deeper motivation behind his absence.
(D): Overlook the "no show" and move on to the next session | Remind the client about your cancellation policy | A | It is best to remind the client of your cancellation policy. It benefits the client more to have the appropriate consequence as motivation for modifying his actions. Also, you deserve to have clients who respect and value your time and who can maintain their commitments. Therefore, the correct answer is (C) | professional practice and ethics |
639 | Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported. | First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom. Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school. During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience. As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself. Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions. Third session As the session progresses with Logan, you notice that he seems more withdrawn and less willing to participate in your planned activities. You ask him how he has been feeling since your last session and if he has progressed in handling the bullying situation at school. Logan hesitates to answer your questions, looking down and avoiding eye contact. He eventually shares that the bullying has intensified and he feels overwhelmed and helpless. He tells you about the boys in his gym class calling him names and making fun of him. He says they continue to bully him, says he "won't ever go to school again," and "hopes those boys die." As an REBT practitioner, you emphasize the importance of determining some of his core issues contributing to his distress. You ask him to share some of the thoughts he has had about the bullying and the boys in his gym class. Logan admits that he believes he is "worthless" and "deserves the bullying" because he is not "cool" enough. You help him recognize that his self-worth is not dependent on the opinions of his bullies and that he does not deserve to be mistreated. You also address Logan's intense emotions and help him understand the relationship between his thoughts, feelings, and actions. You encourage Logan to reflect on the possible consequences of wishing harm upon his bullies and discuss alternative, healthier ways of coping with his feelings. You introduce Logan to relaxation techniques, such as deep breathing exercises and progressive muscle relaxation, which he can use to manage his emotional distress. In this session, you also explore Logan's social support network to identify potential allies to help him deal with the bullying. You ask him about friends, family members, or other school staff who he trusts and feels comfortable talking to about his experiences. Logan mentions a few friends who he thinks might be willing to help. You discuss ways he can approach these individuals and ask for their support, emphasizing the importance of open communication and honesty. When he gets ready to leave, you notice a cigarette fall out of his backpack. You ask him about the cigarette, and he admits that one of the boys in his gym class gave it to him. He says the boy said if Logan smoked it, he would be "cool" and finally accepted by them. You explain to Logan that smoking is not an excellent way to fit in and can harm his health. Instead, you encourage him to find other ways to express himself, such as participating in activities he enjoys or joining clubs at school. Following today's session, you check in with Logan's mother. You also advise her on how she can support her son by having conversations with him about the importance of making good choices and helping him find healthy ways to cope with his feelings. Ninth session Logan arrives at the session a few minutes late and apologizes. He says that he was outside playing kickball with his class. He reports that he has been feeling better about being in school lately. His classmates are friendlier to him, or at the very least, "they don't bother me so much," He is now eating lunch back in the lunchroom. He is learning to play soccer and plans to ask his parents if he can join the summer league. Next, you call Logan's mother and share his progress in counseling with her. Finally, you examine Logan's care plan and assess for any changes needed. Logan's progress in counseling has been notable as he has demonstrated increased social engagement and involvement in extracurricular activities. It appears that the therapeutic interventions implemented have successfully addressed his initial concerns regarding social anxiety and peer relationships. In addition, Logan's newfound interest in soccer and desire to join a summer league further demonstrates his willingness to engage with peers and develop new skills. In conversation with Logan's mother, you emphasize the importance of fostering a supportive home environment to encourage Logan's growth and self-confidence. The mother expresses gratitude for the improvements in her son's well-being and commits to facilitating Logan's involvement in the summer soccer league. Additionally, she agrees to maintain open communication with the counselor to address any potential concerns that may arise in the future. Upon reviewing Logan's care plan, the counselor determines that the current therapeutic goals and interventions remain appropriate and relevant to Logan's ongoing progress. However, it may be beneficial to introduce supplementary strategies to further enhance his self-esteem and resilience and promote effective communication and problem-solving skills. By doing so, Logan will be better equipped to navigate any challenges that may emerge as he develops and maintains positive relationships with his peers. After the session, you receive a phone call that your wife has passed away. In the midst of the sudden loss of your beloved wife, you find yourself struggling to maintain your usual level of composure, which is understandable, feeling overwhelmed and emotionally drained during this difficult time. Being a therapist, you recognize the weight of your emotional burden and decide to reach out to your supervisor to discuss your struggles. After a heartfelt conversation, you feel a sense of relief and connection with your supervisor, who has provided you with support and understanding. As the conversation draws to a close, you make an unexpected request of your supervisor: that she attend your wife's memorial and wake so that she can meet your family and share in the memories of your loved ones. This request may seem a lot to ask, but you feel comforted by the thought of having someone close to you share in this challenging time. You also ask if she can take over your caseload as you deal with your wife's passing. | The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family. | What is the most appropriate response for your supervisor to give when you invite them to attend your wife's memorial service and wake? | The supervisor may opt to attend the memorial and wake. | The supervisor should take over your caseload without attending the memorial service or wake, as the supervisor's professional duty is to ensure clients' needs are met. | The supervisor should express understanding towards the supervisee and recommend seeking an alternate therapist than herself to oversee clients while away. | The supervisor may opt to attend the memorial and have a brief interaction with you to show support. | (A): The supervisor may opt to attend the memorial and wake.
(B): The supervisor should take over your caseload without attending the memorial service or wake, as the supervisor's professional duty is to ensure clients' needs are met.
(C): The supervisor should express understanding towards the supervisee and recommend seeking an alternate therapist than herself to oversee clients while away.
(D): The supervisor may opt to attend the memorial and have a brief interaction with you to show support. | The supervisor may opt to attend the memorial and have a brief interaction with you to show support. | D | Having the supervisor attend the memorial can be appropriate and supportive as long as both parties are mindful of dual roles and boundaries. Therefore, the correct answer is (A) | professional practice and ethics |
640 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | The client is attending group therapy and reports it helps him feel less isolated and alone. He has learned from the group leader and group participants that other medications (i\. e., second-generation atypical antipsychotics) have fewer side effects, and he has requested a psychiatric medication evaluation. The client states he is constantly worrying about “the shadow man,” which has taken its toll physically. He recounts a recent visit with his parents where his father blamed him for his mother’s anxiety. During the same visit, his father criticized the client’s poor choices in life and, according to the client, “He guilt-tripped me for not being more like my brother.” The client believes his parents are to blame for his current situation because they ignored his needs once he reached adolescence and refused to help when he was struggling | Which of Yalom’s curative factors does the client experience when saying he feels less isolated and alone? | Cohesiveness | Universality | Catharsis | Instillation of hope | (A): Cohesiveness
(B): Universality
(C): Catharsis
(D): Instillation of hope | Universality | B | Universality helps members feel less isolated and alone by learning that others share some of the same issues and problems. Psychosocial interventions are included in best practices for individuals with schizophrenia. Treatment generally consists of psychoeducation and social skills training, with group therapy serving as the primary treatment modality. Cohesiveness is theweaspect of group therapy. It is different from universality in that cohesiveness reflects unified members, whereas universality is experienced when one realizes they are not alone. The installation of hope helps members have a positive outlook on the future. Catharsis is the release of feelings expressed in a safe group environment. Therefore, the correct answer is (B) | counseling skills and interventions |
641 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintainappropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but theyparticipate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | You meet with the group for the sixth session, and they are focused and appear to be more respectful toward you because it appears that you can get their attention more easily to start the session. You separate the group into dyads at the start of the session and prompt the group members to talk about feelings related to the pros and cons of engaging in school. You overhear client 4 telling client 3 that it does not matter if client 3 does well in school because he is in juvenile detention for sexual assault and therefore he cannot redeem himself. You intervene and remind client 4 of the group rules about respecting others. You notice that one group member appears to be sexually attracted to another group member | You notice that one group member appears to be sexually attracted to another group member. Which of the following options would be the most likely to support the group goals? | Remind the group members that they cannot have a relationship with each other. | Discuss with the involved individuals that an outside relationship could adversely affect the group process. | Continue to monitor how the relationship affects the group because individuals will do what they want regardless of the group rules. | Discuss the relationship dynamics with the group because others may feel that the relationship is affecting group processes. | (A): Remind the group members that they cannot have a relationship with each other.
(B): Discuss with the involved individuals that an outside relationship could adversely affect the group process.
(C): Continue to monitor how the relationship affects the group because individuals will do what they want regardless of the group rules.
(D): Discuss the relationship dynamics with the group because others may feel that the relationship is affecting group processes. | Discuss with the involved individuals that an outside relationship could adversely affect the group process. | B | It would be most helpful to talk with the involved individuals about their relationship and how it might adversely affect the group’s process. Discussing the group rules, relationship dynamics, and monitoring the effects on the group will be helpful, but individuals will often proceed with the relationship anyway. Therefore, the correct answer is (D) | counseling skills and interventions |
642 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | k and Family History: The client obtained her bachelor’s degree in teaching and is currently a certified teacher. She comes from a family of educators, with her mother working as a teacher and her father as a high school guidance counselor. Before college graduation, she worked odd jobs, including waiting tables and working in a public library with preschool groups. She remembers enjoying her student teaching position but states that the class was “nothing like” what she has now. She explains that her student-teaching classroom contained 16 students and that she now struggles to stay on top of her current class of 24. She plays on a tennis team and serves as a “big sister” to a child through a local nonprofit organization. The client is married, and she and her husband do not have children. She reports that her husband has a high-stress job working as an attorney. The client says that he has “little patience with me when I complain about my job stress | In the DSM-5-TR, which of the following is considered the essential feature of adjustment disorders? | Emotional or physical symptoms in response to an identifiable stressor | Emotional or behavioral symptoms in response to an identifiable stressor | Emotional or physiological symptoms in response to an identifiable stressor | Emotional or cognitive symptoms in response to an identifiable stressor | (A): Emotional or physical symptoms in response to an identifiable stressor
(B): Emotional or behavioral symptoms in response to an identifiable stressor
(C): Emotional or physiological symptoms in response to an identifiable stressor
(D): Emotional or cognitive symptoms in response to an identifiable stressor | Emotional or behavioral symptoms in response to an identifiable stressor | B | According to the DSM-5-TR, the presence of emotional or behavioral symptoms in response to an identifiable stressor is the first criteria and the essential feature of adjustment disorders. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
643 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. Fourth session Last week you met with the client's parents to discuss behavioral parent management training, educating them on how this approach can be used to decrease disruptive behavior and encourage positive behaviors. You taught them how to identify and reinforce desired behaviors and asked them to start keeping a log to record the client's behaviors during the day, what actions they took in response to his behaviors, and how he responded. Additionally, you suggested introducing rewards for meeting goals and discussed the importance of consistency. They followed up with you prior to today's appointment, stating that they believe the parent management training has been beneficial so far, as they have seen a slight decrease in disruptive behaviors and an increase in compliance. The client arrives for his fourth individual session with you. When you ask him how he has been feeling this week, he states that he does not want to go to math class because they "move too fast," and he cannot keep up. The client says he does not feel it is fair that "the teacher yells at me every day even when I'm trying my best." He says, "She's mean, and I won't go back to her class ever again!" He is displaying signs of anger and frustration. His arms and legs are tense, he is tapping his feet, and his facial expression is scrunched up in a frown. His breathing is shallow and rapid. You attempt to calm him down by guiding him in a breathing exercise that you first introduced during a previous session that involves taking slow, deep breaths. You repeat this exercise a few times with the client until he is feeling calmer. In order to further explore the client's feelings about math class, you ask that he draw a picture of the classroom and how it makes him feel. He draws an angry teacher standing in front of a chalkboard with a lot of numbers written on it in random order. The client says that this is how his math class feels to him: overwhelming and confusing. You explain to the client that you understand how overwhelmed and confused he feels, and that it can be really hard to focus on a task when it feels too hard. You also assess the client's perceptions of the teacher, noting his feelings of mistrust and apprehension. Additionally, you assess the client's ability to self-regulate in the classroom and his overall attitude towards class participation. You talk to him about some strategies to help him feel more comfortable in class, and you also reassure him that you are going to talk to his math teacher. Ninth session The client, his parents, and the math teacher present to your office. The teacher reports that the client seems to be achieving academic success with the addition of having a separate location for tests and extra time to complete assignments. The parents state they see improvement at home after deciding to put him on Ritalin. They are smiling as they report that their son seems to have entered a "new phase." His progress is evident in his increased engagement in the classroom and his improved academic performance. He is able to follow instructions and complete assignments in a timely manner, and is better able to interact with his peers. His attitude towards class participation has improved and he is able to self-regulate his emotions better. He has also expressed an increased level of self-esteem and self-efficacy in math class. Overall, the client has demonstrated improved functioning in the academic arena and the addition of Ritalin has helped him to become more alert and focused. The client appears content and keeps asking if it is time to go back to class yet. To further ensure successful progress and to provide additional support for the client, you suggest that the teacher and parents have consistent and frequent communication about the client’s academic progress. You recommend that the teacher provide regular feedback and encouragement to the client, and you suggest that the parents continue to provide a structured and supportive environment at home. Additionally, you discuss potential academic supports that the parents may consider to help the client maintain his academic progress. Finally, you suggest that the client continue to utilize his self-regulation strategies and other coping skills to manage any anxiety or other challenging emotions related to math class. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | You tell the client that when you were his age, you had trouble with math and could not keep up. What did you do here as the therapist? | Redirected the session | Created a new narrative for the client | Used appropriate self-disclosure | Crossed a boundary | (A): Redirected the session
(B): Created a new narrative for the client
(C): Used appropriate self-disclosure
(D): Crossed a boundary | Used appropriate self-disclosure | C | You demonstrated self-disclosure. Self-disclosure can be appropriate as long as it does not take away from the client. Therefore, the correct answer is (A) | counseling skills and interventions |
644 | Client Age: 14 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Asian-American (Karen) Grade: 8th Counseling Setting: Child and Family Services Agency Type of Counseling: Individual and Family Presenting Problem: Substance Misuse and Acculturation Difficulties Diagnosis: Substance Use Disorder, Moderate (F2.911 ); Acculturation difficulty (V62.4 Z60.3) | Mental Status Exam: The client is polite and cooperative. He is neatly dressed and is the only member of his family who is not wearing traditional Karen clothing. His affect is restricted, and his eye contact is poor. The client denies suicidal and homicidal ideation. He reports feeling anxious and sad frequently. He expresses that he is particularly worried at school and has had a difficult time adjusting. The client states that he lived in outdoor homes and buildings before coming to the United States. He explains, “Here, I feel like I’m trapped in a c | You are working as a counselor in a child and family mental health agency. A 14-year-old Asian-American male presents with family members who are concerned about the client’s drug use. The family is part of an ethnic population from Southeast Asia who resettled in the United States just under two years ago. The client is fluent in English and interprets for the family. The client goes to a public school specifically designed to improve English proficiency and has, until recently, done well academically. The parents have limited English proficiency (LEP). The parents provide a letter from his school stating the client was suspended after administrators found marijuana and amphetamines in the client’s locker. The client expresses remorse and says he became highly anxious and fearful when the school resource officer became involved. He explains, “Where I come from, the police are not there to protect or help.” The client willingly completes a substance use screening assessment, and the results indicate he is at risk for meeting the diagnostic criteria for substance use disorder. | The client is now attending family therapy with his parents and has made progress. His last four drug screens have been negative, and the client is beginning to show insight into his problem. The parents have improved with limit setting and are learning how to help the client achieve a healthy sense of identity. The parents are becoming better acclimated to the United States and have developed stronger connections within their church and community | Which graphical depiction would you use to represent the client’s family dynamics, including cross-generational coalitions, subsystems, and other significant interactions? | Family map | Sculpting | Ecomap | Genogram | (A): Family map
(B): Sculpting
(C): Ecomap
(D): Genogram | Family map | A | SalvadorMinuchin, credited with developing structural family therapy, used family maps to graphically depict family dynamics, including cross-generational coalitions, subsystems, and differentiated intersectional boundaries. Family maps also show community supports and stressors, making it a good option for assessing protective factors and risk factors within the client’s community. A genogram is also a visual depiction of family dynamics and is commonly associated with multigenerational (extended) family systems therapy, also known as Bowenian therapy. Family maps differ from genograms in that family maps show family dynamics and identify social supports and connections. Genograms depict family interactions and generational relationships to reduce inappropriate boundaries (eg, triangulation) by increasing diffusion. An eco-map is similar to a family map, but the emphasis is on intrafamily dynamics within their current social context. For this client, identifying social relationships and connections within the community can help determine protective factors (eg, church, school) and identify risk factors (eg, social isolation, peers) for the parents and the client. Eco-maps differ from genograms and family maps by viewing family boundaries as either open or closed to their social environment. Virginia Satir used sculpting as a human validation process model technique. Sculpting is a nonverbal exercise in which counselors instruct family members to physically position themselves to represent certain aspects and patterns of family relationships and interactions. Therefore, the correct answer is (B) | counseling skills and interventions |
645 | Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center | The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments. | First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you. Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!" You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates. 10th session During your last session with the client, she discussed the anxiety that she was feeling about going home for winter break in a few weeks. She told you that her mom and stepdad always prepare a large meal for the holidays, and the extended family members get together to eat. She expressed a desire to participate in the family festivities but concern about her mom and stepdad's lack of understanding about her illness. She told you, "I don't want to make anyone feel bad, but I just can't eat like everyone else. It's not only the food - it's the conversations and comments about my body that really bother me." You listened as she expressed her fear of disappointing her family and reassured her that is was okay to set boundaries and have conversations about food. Together, you brainstormed coping strategies to manage her anxiety. You also suggested that she bring a dish of food that she would be comfortable eating to the winter break gathering. At the end of the session, she asked if she could bring her parents to the next session in an effort to gain their support and to help them understand what she is going through. You agreed to her request and scheduled an appointment to meet with the client and her parents. At the start of today's session, you introduce yourself to her parents and explain your role in helping their daughter. The client's mother tearfully shares that she had no idea her daughter was struggling so much and that she wishes she had picked up on the signs sooner. The stepfather appears quiet and reserved. You help guide a conversation between the client and her parents about her eating disorder and symptoms that she is experiencing. The client shares her fears, triggers, and struggles around food. Her stepfather speaks up and says, "I've heard enough. This is just ridiculous. You should just be able to eat, like everyone else. Your generation has gone 'soft' and started making up problems. There are people out there who don't have any food. When I was growing up, we had nothing. Your behavior is disrespectful." As he is talking, the client's mother is quiet and visibly uncomfortable. The client interjects, "Are you kidding? I'm the one who's being disrespectful?" She looks toward you and says, "When I'm home, he cooks these extravagant meals and refuses to let me leave the table until I've eaten what he's served me because it's 'wasteful to throw away food.' It's abuse! I feel like a captive when I'm at home." She looks back at her stepfather and says, "All I'm asking is that you understand what I'm going through and try to be a little more supportive." The stepfather's face turns red with anger, and he gets up to leave the room. You intervene and ask him to stay, offering a suggestion that you all take a few moments to reflect on what each person has shared before continuing the conversation. While the stepfather takes a break, you encourage the mother to open up and express her feelings. She reveals that she is scared of not being able to help her daughter and feels helpless in understanding how to come together as a family. You discuss ways that she can be supportive and provide an empathetic environment for her daughter. | The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row. | What approach should you take to provide the client's parents with information about Anorexia Nervosa? | Psychoeducational approach | Psychodynamic approach | Cognitive-behavioral approach | Systems approach | (A): Psychoeducational approach
(B): Psychodynamic approach
(C): Cognitive-behavioral approach
(D): Systems approach | Psychoeducational approach | A | A psychoeducational approach would be most appropriate to share information with the client's parents about the nature of her illness. Therefore, the correct answer is (C) | professional practice and ethics |
646 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | her. Family History: The client says that she has a good relationship with her parents. She says that they are encouraging and supportive of her. The client says that she has a younger brother who is 6 years old and an older brother who is 16 years old. The client states that she has a good group of friends and spends time with them regularly | All of the following are appropriate short-term treatment goals EXCEPT: | Assisting the client with identifying barriers to school attendance | Referring for psychological testing to determine the cause of the refusal to attend school | Building trust so the client can feel comfortable enough to begin to identify and express feelings regarding her school attendance | Beginning to discuss increasing social connectedness due to withdrawn behavior | (A): Assisting the client with identifying barriers to school attendance
(B): Referring for psychological testing to determine the cause of the refusal to attend school
(C): Building trust so the client can feel comfortable enough to begin to identify and express feelings regarding her school attendance
(D): Beginning to discuss increasing social connectedness due to withdrawn behavior | Referring for psychological testing to determine the cause of the refusal to attend school | B | Referral for psychological testing likely would not return much helpful information because the client is not comfortable enough to talk about what is happening. The goals should be achievable and should be relevant to the presenting situation. Building trust and identifying barriers to school attendance are important because this is the only obvious presenting problem even with minimal client participation. The focus on improving social connectedness is important due to withdrawn behavior. Therefore, the correct answer is (B) | treatment planning |
647 | Client Age: 74 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual and psychoeducation Presenting Problem: Memory impairment Diagnosis: Mild Neurocognitive Disorder (MND) Unspecified with Behavioral Disturbance (apathy and mood disturbance) 799.59 (R41.9) | Mental Status Exam: The client is appropriately dressed and cooperative. She is tearful at times and often glances over at her daughter when she is unsure of how to respond to a question. The client denies suicidal and homicidal ideations. She is oriented to the day, month, and year, but she could not recall the date or place. She recalls the city with prompting. The client’s sleep is fair, and her appetite is normal. She reports feeling sad most of the day, every day. To date, medical procedures used to determine the etiology of the client’s cognitive impairment have been inconclusive. She awaits an appointment for a positron emission tomography (PET) scan, which can help determine the presence of brain activity associated with Alzheimer’s disease. She denies substance use and says that she is a social drinker. Her judgment and awareness are fair, and she denies audio and visual hallucinations. Fam | You work in a mental health center and are conducting an initial assessment on a 74-year-old Caucasian female. The client and her daughter arrive today with a copy of the client’s recent neuropsychological evaluation. The evaluation shows cognitive functioning deficits, and the neuropsychologist has diagnosed the client with mild neurocognitive disorder (MND). The client and her daughter fear that her memory issues could worsen and impact her independence. The daughter has seen a gradual decline in the client’s memory, which coincides with episodes of depression. The client expresses embarrassment over her memory issues and states, “remembering the simplest things—like doctor’s appointments or paying bills—has started to become more and more difficult.” She states that she no longer participates in things she once enjoyed, including her book club, church services, and fitness classes. | ily and Work History: The client divorced nearly 15 years ago and has lived alone since. She has two adult children and four grandchildren who all live locally. She reports experiencing depression and anxiety for most of her life. She currently takes an antidepressant and has done so for years. The client’s career was in school administration, where she dedicated nearly 30 years of service until retiring 6 years ago. She reports that retirement caused an increase in depression as she grieved the “loss of (her) identity.” The client’s mother had Alzheimer’s disease, which placed significant stress on the client and her father. The client’s sister is diagnosed with bipolar disorder, and there are no other noted mental health or substance use disorders in the family | Which one of the following is true of individuals with mild neurocognitive disorder? | Cognitive deficits interfere with activities of daily living (i.e., bathing, dressing) | Cognitive deficits occur exclusively in the context of delirium | Cognitive deficits do not interfere with the capacity for independence | Cognitive deficits interfere with successfully completing tasks such as paying bills and other complex instrumental activities | (A): Cognitive deficits interfere with activities of daily living (i.e., bathing, dressing)
(B): Cognitive deficits occur exclusively in the context of delirium
(C): Cognitive deficits do not interfere with the capacity for independence
(D): Cognitive deficits interfere with successfully completing tasks such as paying bills and other complex instrumental activities | Cognitive deficits do not interfere with the capacity for independence | C | According to the DSM-5-TR’s description of mild neurocognitive disorder, the diagnosis of mild neurocognitive disorder is marked by a modest decline in cognitive functioning. Individuals with mild neurocognitive disorder exhibit moderate difficulty with memory, planning, organization, attention, learning, or processing social cues, but these do not interfere with performing everyday activities independently and are often managed with the use of compensatory strategies, such as keeping a written schedule, the use of mnemonics, assistance with organization, and related accommodations. It is not true that these deficits must occur exclusively in the context of a delirium, nor are deficits so severe that they disrupt activities of daily living or instrumental activities of daily living. Therefore, the correct answer is (C) | professional practice and ethics |
648 | Name: Gordon Clinical Issues: Mood instability and substance use leading to occupational impairment Diagnostic Category: Bipolar and Related Disorders;Substance Use Disorders Provisional Diagnosis: F31.0 Bipolar I Disorder with Rapid Cycling; F10.20 Alcohol Use Disorder, Severe Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client appears to the intake session disheveled and displaying a strong presence of body odor. He is inconsistently cooperative within the session. His mood and affect are anxious and labile. His attention and concentration are impaired, and he is easily distracted in the session. He admits to his recent suicidal ideations and hospitalization but minimizes the impact stating, "Everyone overreacts these days." He mentions that when he was in his 20s, he was prescribed Lithium. He denies any homicidal ideations and displays no acts of delusion or hallucination. The client's ability to abstract and generalize is slightly lower than average. The client grapples with his impulse control regarding alcohol. He has insight into the level of the illness with which he is struggling but lacks judgment when making healthy choices. | First session You are a mental health therapist in an agency. The client, a 33-year-old former cab driver, comes to see you per his hospitalization discharge. The client's speech is characterized by an increased rate of speech, tangentially, and circumstantiality. He reports feeling overwhelmed and out of control, often losing his temper and having difficulty regulating his emotions. He reports a history of alcohol abuse, as well as self-medicating to cope with his emotional distress. He states that he has lost his job due to his difficulty controlling his emotions, and he is hopeful that therapy can help him regain his job. He also reports a history of legal trouble and has been incarcerated multiple times in the past. His legal record shows a history of violent offenses and domestic abuse. After the initial interview, you review the paperwork from the client. You recognize his last name and realize he is a distant cousin by marriage, although this is your first time meeting him. You consider the ethical implications of continuing to see him for therapy along with the possibility of transferring him to one of your colleagues. Third session After determining that you would be able to remain objective with the client, you met with him for a session and continued your assessment. You recommended seeing him once a week for therapy sessions and asked him to check in with you between sessions. You also provided him with a referral for a psychiatric evaluation to determine if medication was warranted for mood stabilization. Today is your third counseling session, and the client arrives 10 minutes late. The client's behavior during the session was increasingly concerning. He appeared disheveled, and his speech was slurred and jumbled, indicating that his level of intoxication was likely high. The client exhibited bizarre behaviors and laughed inappropriately, indicating a potential manic or hypomanic episode. His attention span during the session was limited, and he could not focus on the topics at hand. When asked, the client admits to drinking before the session and is unable to provide an accurate account of how much he has consumed. He reports going to the local bar down the street from his house to have "one drink." He is also unable to provide any information on the location of his emergency contact. This lack of insight and awareness of his current intoxication, combined with the inappropriate behaviors he is exhibiting, prompts you to assess for the next level of intervention that is needed. | The client had a history of alcohol abuse and had been warned multiple times by his employer to stop drinking while on the job. The client's boss tried to counsel him, but he refused to accept help or advice. Instead, he continued driving while under the influence, and his reckless behavior eventually led to an accident. As a result, the client was dismissed from his job and has struggled ever since. The client has been unsuccessful in finding other employment due to his record of drinking on the job. He has been trying to seek help with his drinking but without any success. He believes that therapy may be his last hope for getting his job back, and he is desperate to change his life. The client tells you, "I started drinking years ago. I've tried to quit, but I can't do it." He further states, "It used to be a couple of beers, but that doesn't do it for me anymore. So now, I drink almost half a bottle of whiskey a day. I usually start in the morning because if I don't, I feel terrible; my hands shake, I feel clammy, and I get an upset stomach. For years, I used just to let the mood pass, but in the last year or so, the alcohol has helped." | Given your inability to reach the client's emergency contact, what is the most appropriate action to take at this time? | Call the hospital for readmittance | Immediately contact the police | Contact a mobile crisis unit | Stay with the client in the office until he is sober | (A): Call the hospital for readmittance
(B): Immediately contact the police
(C): Contact a mobile crisis unit
(D): Stay with the client in the office until he is sober | Contact a mobile crisis unit | C | Mobile crisis can safely get the client back to his home. Therefore, the correct answer is (B) | professional practice and ethics |
649 | Client Age: Client 1: Age 18 Client 2: Age 21 Client 3: Age 22 Client 4: Age 19 Client 5: Age 18 Sex: Male and female Gender: Male and female Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: All members are single Counseling Setting: Counseling clinicType of Counseling: Group and individual counseling Presenting Problem: All individuals are seeking support for struggles related to borderline personality disorder. Diagnosis: Borderline personality disorder (F60.3) | Mental Status Exam: All clients appear to be oriented to time, situation, location, and person. The clients are all dressed appropriately for the weather. No clients appear to experience any visual or auditory hallucinations. Most of the clients are presenting as friendly but gua | You are a licensed therapist running a dialectical behavior therapy (DBT) group for young adults. You also provide a weekly individual counseling session for each group member, which is common practice for DBT group therapy. During the first session, you provide psychoeducation on DBT and the group process. Most of the members seem closed off and sometimes aggressive in response to being asked to speak during the first session, which can be consistent with borderline personality disorder. Client 3 becomes upset about halfway through the session, stating that he does not need to participate because the group will eventually end, so he does not need to build relationships with the group members. You end the session by planning individual therapy sessions with each group member. | You meet with the group and continue DBT psychoeducation regarding distress tolerance. About halfway through the group, you notice that client 4 has not shared much, and you ask her about this. The client states that every time she wants to talk, she cannot find a way into the conversation because others are talking. This group is in the working stage of group therapy, they are actively engaged in the session, and they are all also actively engaged in individual therapy | All of the following are core concepts of distress tolerance in DBT, EXCEPT: | A pros and cons list | Thought stopping | Self-soothing | TIPP | (A): A pros and cons list
(B): Thought stopping
(C): Self-soothing
(D): TIPP | Thought stopping | B | Thought stopping is a CBT technique that is focused on stopping unhelpful thoughts before they affect functioning. TIPP (temperature, intense exercise, paced breathing, and paired muscle relaxation) is a method that helps support management of the physical symptoms of distress, therefore building distress tolerance. A pros and cons list supports the decision-making process and is part of building distress tolerance in DBT. The ability to self-soothe is also important in building distress tolerance in DBT because it involves coping with present emotions and feelings. Therefore, the correct answer is (D) | counseling skills and interventions |
650 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e\. g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmental and Family History: The client’s mother and father are married, and the client has a sister who is 3 years old. The mother denies drug or alcohol use during pregnancy. She is a smoker but states that she cut down when she discovered she was pregnant with the client. The client was delivered at 34 weeks and weighed 5 pounds and 6 ounces. He stayed in the newborn intensive care unit for 10 days after delivery. The client was toilet trained at 24 months, walked at 12 months, and talked at 18 months. The client’s paternal grandmother has been treated for bipolar disorder. His maternal uncle has a history of substance abuse, which his mother cites as the reason why she is opposed to the client going on medication. You would like to use ADHD interventions consistent with evidence-based practices (EBP) | You would like to use ADHD interventions consistent with evidence-based practices (EBP). Components of EBP include all of the following EXCEPT: | The clinician’s knowledge, skills, and expertise | Research evidence with the least probability of bias | Cost-effectiveness and duration of treatment | The client’s culture, preferences, and values | (A): The clinician’s knowledge, skills, and expertise
(B): Research evidence with the least probability of bias
(C): Cost-effectiveness and duration of treatment
(D): The client’s culture, preferences, and values | Cost-effectiveness and duration of treatment | C | Cost-effectiveness and duration of treatment are not components of EBP. Instead, EBP includes three factors: (1) the clinician’s knowledge, skills, and expertise; (2) the client’s culture, preferences, and values; and (3) research evidence with the least probability of bias (ie, the best available research evidence). Experts including Norcross and Wampold (2011) have advocated for incorporating the therapeutic relationship into the definition of EBP. Therefore, the correct answer is (C) | treatment planning |
651 | Name: Deb Clinical Issues: Worry and anxiety Diagnostic Category: Other Mental Disorders and Additional Codes Provisional Diagnosis: 300.9 Unspecified Mental Disorder Age: 40 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The general appearance is of a 40-year-old female of average height and obese weight. Her hygiene is within normal limits. The client seems a bit nervous when you begin your initial interview. She says, "It's 'wine Wednesday' right? I wish I had a glass of wine right now to steady my nerves. A couple of glasses would really help right about now." The client is alert and oriented x4, cooperating fully with the exam. Motor activity is within normal limits. Speech is within normal limits for rate, articulation, verbosity, and coherence. There are no signs of impairment in attention, concentration, or memory. There are some signs during the exam of deficits in impulse control. | First session You are a mental health therapist in a private practice setting. The client, a 40-year-old female, arrives for the intake and discloses concerns about her physical health. She has felt that the "doctors are missing something" for years. She "feels sick all the time" but cannot describe specific symptoms other than general fatigue. The client reports feeling incredibly frustrated by the "lack of care" she receives. She was provided with a referral to contact you and is asking for your help in determining what steps she should take to ensure her health and safety. You notice that the client is becoming tearful as she describes her situation. You complete a biopsychosocial assessment and explore various aspects of the client's life and history, including her family dynamics, current living situation, lifestyle habits, and any stressors in her environment. The client indicates that she has a supportive family and has been open with them about her concerns regarding her health. She is also actively working to improve her diet and exercise, but has found this process to be challenging due to lack of motivation. Although she does not have any diagnosable mental illnesses, the client reports feeling anxious and overwhelmed lately, particularly when it comes to work. The client discloses feeling overwhelmed by her new role as charge nurse and is worried that she might not be able to manage all of her responsibilities effectively. She also expresses concern over how her weight may affect her ability to be successful in her career. Fifth session The client missed last week's appointment and rescheduled to see you today. Before she sits down in the chair, she hands you a file with her medical records and blood work. She explains that she made copies for you to review. You discuss how she has felt since meeting with you. She uses various clinical terminology when describing her feelings and reports "battling anhedonia." It is difficult for her to enjoy going anywhere as she is constantly worried that she will contract a disease. She states that her anxiety has caused her to make some mistakes at work which she is very upset about. You notice that the client is wringing her hands together and biting her lips. You state to the client, "It sounds like you're really struggling with your anxiety. I noticed that you were talking about some of the mistakes you feel like you make at work because of your anxiety. Can you tell me more about that?" The client replies, "Yeah, it's so embarrassing and frustrating. Whenever I go out, and especially when I'm at work, I feel like everyone is judging me for my weight. It's like they think I'm not good enough because of it. I start to question myself and mess something up." You ask the client, "Have people actually said anything to you about your weight?" She responds, "No, but I can tell they're thinking it." As the therapist, you are able to observe how the client's cognitive biases may be contributing to her distress. You acknowledge her emotions, while also highlighting that she is facing challenges associated with being in a demanding role at work. You utilize cognitive-behavioral strategies with an emphasis on mindfulness practices to help her manage her feelings. You also discuss possible coping mechanisms that could help her manage the stress of her job. At the end of the session, you summarize what you have worked on and schedule her next appointment. Tenth session It's been two and a half months since you first started seeing the client for weekly therapy sessions. Today, your client appears calm and relaxed. You review her progress and highlight her areas of growth since the start of therapy. The client states that she feels more empowered to challenge her negative thoughts and is able to recognize when her anxiety is beginning to spiral. She has been using the coping skills she learned in the previous sessions to manage her stress levels more effectively. The client also reports a weight loss of 5 pounds since beginning therapy, which she is pleased with and attributes to the mindfulness techniques she has been practicing. You discuss her weight loss and the importance of mindful eating practices. You explain to the client that weight loss is a secondary outcome of therapy and that it is more important to focus on living a healthy lifestyle than a number on a scale. The client expresses her understanding and appreciation for the guidance. When you ask her to rate her level of anxiety, she indicates that she is much less anxious than when she first started therapy. Her preoccupation with illness has decreased, though it has not gone away completely. She reports that her colleagues have noticed the change in her attitude and confidence. She is able to stay present and focus on her job, without constantly worrying about negative judgement from her co-workers. She tells you that she has been keeping up with the journaling homework that you assigned in a previous session and it has been a helpful outlet for her to express her thoughts. She has also been practicing progressive muscle relaxation during her breaks at work and after she gets home in the evenings. The client is still drinking wine to help her relax, but you have determined that her alcohol use does not warrant clinical intervention. You discuss spacing out your sessions and she agrees to try meeting with you twice a month. At the end of the session, she asks if you could email her a copy of her therapy records so that she can refer back to them periodically in order to continue making progress. | The client has a strong support network. She says that she is especially close with her mother, aunt, and two older sisters. The client goes on to explain that growing up she was close with her sisters, but because they were so far apart in age, they did not always get along. She remembers feeling like the black sheep amongst her older sisters since she was the youngest and had different interests from them. Her father was often away for work, which meant that her mother was the primary caretaker. Despite this, she speaks fondly of her parents and credits them for providing a stable home life. She indicates that her father was recently admitted to a nursing home for dementia. The client reflects on how her father's illness has been hard to process. She remembers when he began to forget familiar places and people, as well as not being able to recognize himself in the mirror. His illness has been difficult for the family to accept, but they are working on a schedule to make sure that a family member sees him every day. The client has been working in the healthcare profession for over 15 years, and she currently works as a nurse at a local hospital. She discloses that she recently received a promotion to a "charge nurse." She has mixed feelings about the promotion. She states that she loves nursing, but sometimes worries about how she is perceived by her colleagues due to her weight. She fears being seen as lazy and unmotivated because of her appearance, which she believes is not in line with the expectations of a charge nurse. Overall, she experiences low self-esteem and difficulty feeling confident in her professional role due to her weight. She is also concerned that her co-workers may find out that she is seeing a therapist and will think less of her. Pre-existing Conditions: The client states that she is 75 pounds overweight according to her physician. She has been preoccupied with having an illness for several years and has seen multiple medical specialists. She is concerned that she has cancer or a heart condition "because those issues run in my family." There is no medical evidence to support any of her concerns, and during her last annual check-up, her primary care physician made a referral for her to see you. | What is the most appropriate response to the client's request for her therapy records? | I'm sorry, I don't think it is a good idea for you to have access to your records." | "I'm sorry, but that's confidential information and cannot be shared with you. Do you have any specific concerns that we could discuss in session?" | "Due to privacy and confidentiality laws, I'm not able to email them to you, but I can make a copy for you and give them to you in person or by mail." | "I'm happy to provide you with a copy of your therapy records. I just need to verify that I have your current email address and I can send your records to you later today." | (A): I'm sorry, I don't think it is a good idea for you to have access to your records."
(B): "I'm sorry, but that's confidential information and cannot be shared with you. Do you have any specific concerns that we could discuss in session?"
(C): "Due to privacy and confidentiality laws, I'm not able to email them to you, but I can make a copy for you and give them to you in person or by mail."
(D): "I'm happy to provide you with a copy of your therapy records. I just need to verify that I have your current email address and I can send your records to you later today." | "Due to privacy and confidentiality laws, I'm not able to email them to you, but I can make a copy for you and give them to you in person or by mail." | C | You explain to the client that due to privacy and confidentiality laws, you are not able to email her a copy of her therapy records. You offer to make a copy for her and provide it in person or by mail. You discuss the importance of confidential communication between therapist and client and how you will handle any requests for information relating to her therapy. Therefore, the correct answer is (C) | professional practice and ethics |
652 | Name: Shelly Clinical Issues: Emotional dysregulation Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.3 Borderline Personality Disorder Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Never married Modality: Individual Therapy Location of Therapy : Telehealth | The client's clothes are clean but her hair and make-up seem unkempt. She wears long sleeves but you notice some scarring on her left wrist when she steeples her hands together in front of her computer screen to answer a question. The client remains alert throughout the interview, though sometimes you have to repeat questions. She seems to be distracted by something off screen at times. She fidgets with a cigarette lighter. The client appears irritable and her affect is labile. The client is coherent. Her speech is unpressured though at times slightly slow. She is oriented to person and place but not time or situation. She is unsure of what day of the week it is and she does not seem to understand the significance of being court-ordered. Her thinking is mostly linear and goal-directed but at times tangential and unfocused. She displays persecutory thought content. Insight and judgment are poor. | First session You are a mental health therapist delivering telehealth therapeutic services. Your 41-year-old Black female client is sitting on her sofa with her arms crossed and an annoyed look on her face. When you first see the client, you are immediately attracted to her as she reminds you of your first wife. She has been mandated to therapy by the Court as part of the terms of her probation. She begins by telling you about her difficulties with her acting career. She recently auditioned for a new role but was turned down because the directors wanted to "go in a different direction." She also mentions relationship distress and tells you she has been dating a high-profile plastic surgeon on and off for two years. She tells you, "We just had a big fight. He said I was 'too high maintenance' and he was tied of 'all my drama' and left. Can you believe it? I was obviously upset and stopped for a drink on the way home and met a very nice gentleman who bought me a few more drinks. But I don't know they think I have a drinking problem." As the intake progresses, it becomes evident that the client's frustration and agitation stem from a deep feeling of abandonment. She expresses her distress over feeling overlooked and not validated in her acting career. She reveals her struggle with the expectations placed upon her as a Black woman in the entertainment industry, believing that systemic biases may be limiting her opportunities. This realization amplifies her anger and resentment, fueling her resistance to therapy and perceiving it as a means of forced compliance rather than genuine support. As you continue to gather information about her presenting problem, you notice that the client is becoming increasingly agitated. Her tone turns angry, and it becomes clear that she resents being in therapy, especially when she says you are "no more than hired help." You attempt to ease tensions and build rapport by sharing with her the names of two famous actors you have counseled. However, this does not change her demeanor or attitude toward you. You detect a recurring theme of self-sabotage that manifests in the client's relationships. She complains about her relationships with the high-profile surgeon and other men. You note the client's lack of trust in men as well as casual female acquaintances who she sometimes sees as "competition." Her relationships appear strained due to her unresolved issues, leading to conflicts and feelings of worthlessness. As you continue your assessment, it becomes apparent that a complex interplay of societal pressures, past traumas, and a deep-seated fear of abandonment negatively impacts her self-perception. You also learn that she worries about her precarious financial situation, which adds to her insecurity and instability. The fear of being unable to meet her basic needs is an artifact of her unstable childhood. You suggest that during the next session, you begin to explore what might be contributing to her current feelings and behaviors beyond just focusing on her career issues, mainly her emotional dysregulation and fears of being abandoned. She says, "I'm an actress and have auditions. How long is this going to take?" You reinforce that the client has been court-ordered to therapy and that therapy will continue for as long as it takes to address the mandated objectives in the court order. You schedule a follow-up appointment to meet with the client again next week. Sixth session The telehealth session starts like any other; you log in and wait for the appointment to begin. However, after several minutes of waiting, you are concerned that something is wrong with the client. When she eventually logs on, she is 15 minutes late and crying uncontrollably. When prompted about what happened, the client begins pouring out her anguish over her boyfriend's recent departure from town on business. She explains how he will not be coming home this weekend like they had planned - leaving her feeling empty and alone. Then, with tears streaming down her cheeks, she says, "I see no reason to go on if he will only cause me grief." At this point, you realize your client might be at risk of self-harm or worse. You spend the remainder of the session developing a safety plan together, which involves finding alternative ways to cope with loneliness and reaching out to friends and family members who can support the client during distress. Despite your best efforts in the session to establish a safety plan, you perceive her adherence to it as shaky. Her body language and verbal feedback clearly show that she struggles to accept the idea of seeking help from her network of friends and family. She confesses feeling like a burden to others, reflecting a deep-seated inferiority complex that seems central to her emotional distress. This, coupled with her inability to visualize the situation from a holistic perspective, implies that she might be caught in the throes of an existential crisis, unable to see beyond the immediate emotional turmoil. Tackling this crisis from an Adlerian lens, you gently challenge her self-defeating beliefs and attempt to imbue her with a sense of belonging and community. However, her tearful responses indicate a sense of discouragement and isolation, suggesting she perceives herself as alone in her struggle. It is apparent her social interest is significantly diminished. You note that this disconnection isolates her emotionally and poses a potential risk to her overall well-being. Despite your attempts to reassure her, she repeatedly questions her self-worth and viability without her boyfriend, mirroring feelings of inferiority and an over-reliance on external validation. In the face of such severe emotional turmoil and potential risk, you recognize that her current mental state may require a more intensive approach beyond the scope of telehealth sessions. This solidifies your intent to seek a higher level of care and immediate intervention for her, emphasizing the severity of the situation and your dedication to safeguarding her well-being. After the client leaves the session, you call her emergency contact and discuss your concerns. You tell the client you are considering referring her for further assessment by a psychiatrist or hospitalization to ensure her safety. You request the client's emergency contact person to call you if they see any indications that the client is decompensating. | The client shared significant details about her familial history, particularly on her father's side. She conveyed that her paternal relatives have contended with various mood disorders, although she could not provide specific diagnostic categories. As a result of her father's authoritarian parenting style of strict adherence to his rules and restrictions, she has rejected any limitations from any authority figures. Notably, she also revealed several severe distressing incidents within her family, including suicide attempts, multiple instances of divorce, and hospital admissions. According to the client, these incidents often emerged due to relational difficulties, culminating in elevated levels of emotional distress. Furthermore, the client reported a history of hospitalization, although her recollection of the admission circumstances was somewhat nebulous. She said that she was feeling "distraught" during that period. You determine that exploring this episode more thoroughly in future sessions when the client feels ready and comfortable could provide valuable insights into her emotional coping mechanisms and resilience. The client was recently arrested for driving under the influence (DUI). This was not her first encounter with law enforcement regarding such a matter, as she has been charged with three DUIs over the past five years. However, this recent incident was markedly different and considerably more severe. She lost control of her vehicle and collided with a residential building, resulting in physical injury to a child. She underwent legal proceedings after her involvement in this accident and was found guilty. As part of her sentence, she was placed on probation under the court's oversight and mandated to attend therapy. The client disclosed that her consumption of alcohol is primarily social in nature. However, she also appears to use alcohol to self-medicate in times of emotional dysregulation. Despite these circumstances and her ongoing encounters with the law, she maintains the belief that her alcohol use does not pose a significant problem. | Based on the current information you have available, why should hospitalization be given strong consideration? | The client is actively at risk of harming herself. She should be hospitalized. | The client has a strong attachment to her boyfriend, and his absence is causing her extreme distress. | The client does not need to be hospitalized. | The client is actively at risk of harming herself. She does not have a strong social support system and a history of impulsive behavior. | (A): The client is actively at risk of harming herself. She should be hospitalized.
(B): The client has a strong attachment to her boyfriend, and his absence is causing her extreme distress.
(C): The client does not need to be hospitalized.
(D): The client is actively at risk of harming herself. She does not have a strong social support system and a history of impulsive behavior. | The client is actively at risk of harming herself. She does not have a strong social support system and a history of impulsive behavior. | D | The client's lack of a strong social support system is particularly troubling. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
653 | Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine | Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns. | Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed. |
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation. | Which objective best supports Leah's application of her treatment plan goal for anxiety reduction? | Leah will write an essay on underlying reasons for anxiety and read it aloud | Leah will report successful daily application of 3+ coping skills within 6 months | Leah will learn 5 new coping skills for reducing anxiety within 6 months | Leah will engage in weekly mindfulness meditation to reduce anxiety | (A): Leah will write an essay on underlying reasons for anxiety and read it aloud
(B): Leah will report successful daily application of 3+ coping skills within 6 months
(C): Leah will learn 5 new coping skills for reducing anxiety within 6 months
(D): Leah will engage in weekly mindfulness meditation to reduce anxiety | Leah will report successful daily application of 3+ coping skills within 6 months | B | This objective assumes Leah has already learned and understands several coping skills to use for anxiety reduction, as per her career knowledge and previous counseling experience; yet it challenges her to apply them in accordance with SMART goals (specific, measurable, achievable, relevant, and timely). Answer a) is not specific enough nor is it timely. Answer c) is unnecessary because Leah already knows coping skills but is just unable to apply them, and answer d) is a supportive objective towards the same goal but does not best support application. Therefore, the correct answer is (B) | treatment planning |
654 | Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support. | First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork. Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care." After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents. | The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle. | When considering an adjustment disorder versus a depressive disorder, what are the most important differentiating factors to assess? | Duration and client's self-report | Duration and parent's report | Duration and assessment scores | Duration and number of symptoms | (A): Duration and client's self-report
(B): Duration and parent's report
(C): Duration and assessment scores
(D): Duration and number of symptoms | Duration and number of symptoms | D | Duration should always be considered when a person is diagnosed with an adjustment disorder. Adjustment disorders are brief in nature. Symptom endorsement/count (either subjectively or objectively) is central, especially when considering a major depressive disorder or an adjustment disorder. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
655 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express | You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex. | Diagnosis: Premature Ejaculation, Acquired, Generalized, Mild (F52.4) ions. Family History: The client reports that he has been in a relationship with his girlfriend for 3 years. The client says that he is close with his parents and his younger brother | Which of the following would be the most helpful area to explore to determine the course of treatment for this client? | Determine if the premature ejaculation is based on medical limitations. | Identify the client’s personal goals for treatment. | Explore the effects of sexual dysfunction on the client’s relationship with his girlfriend. | Determine the effect of the client’s anxiety’s on daily functioning in all settings. | (A): Determine if the premature ejaculation is based on medical limitations.
(B): Identify the client’s personal goals for treatment.
(C): Explore the effects of sexual dysfunction on the client’s relationship with his girlfriend.
(D): Determine the effect of the client’s anxiety’s on daily functioning in all settings. | Determine if the premature ejaculation is based on medical limitations. | A | It is most important to determine what medical limitations the client might have because it is possible that the client’s penis may be excessively sensitive and the premature ejaculation may not be improved through cognitive and behavioral interventions. Identifying the client’s goals, exploring the sexual dysfunction’s effects on his relationship, and identifying the effects that his anxiety has on his daily functioning are all important, but these factors do not matter if biological factors inhibit his progress. Therefore, the correct answer is (A) | treatment planning |
656 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | The client reports that a worker from the local child protective services office met with her and that she is worried about what the coach will do in response when he finds out that she reported him. The client says that she has not returned to school but that the school has provided the classwork and homework needed to keep up; she feels like the school is supporting her well enough to not fall behind. The client confirms that all of the symptoms that she described during her last session are still present | Which of the following would be the most appropriate diagnosis based on the client’s presenting symptoms? | Adjustment disorder, with depressed mood | Post-traumatic stress disorder, with depersonalization | Post-traumatic stress disorder, with delayed expression | Acute stress disorder, with depressed mood | (A): Adjustment disorder, with depressed mood
(B): Post-traumatic stress disorder, with depersonalization
(C): Post-traumatic stress disorder, with delayed expression
(D): Acute stress disorder, with depressed mood | Post-traumatic stress disorder, with delayed expression | C | The symptomatology is consistent with post-traumatic stress disorder, with delayed expression due to presenting symptoms and the 6 months it took for symptoms to reach full post-traumatic stress disorder criteria. Post-traumatic stress disorder with depersonalization is the feeling of experiencing the trauma from the perspective of an outside observer, which is not consistent with reported symptoms. Acute stress disorder would require a time period of 30 days or less, so this would not be an appropriate diagnosis. Adjustment disorder presents as difficulty managing adjustment to life’s stressors; this is not an appropriate diagnosis due to the presenting symptoms. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
657 | Initial Intake: Age: 4 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Clinic Type of Counseling: Individual | Destiny was engaging with the counselor throughout the interview although her affect was flat. She played by herself while the counselor spoke to Darlene and Tony. She did not look up at her parents or engage with them during the entire session. | Destiny is a 4-year-old who was referred for therapy by her preschool teacher. Destiny arrived at the intake session with her adoptive parents, Darlene and Tony Mase. Darlene and Tony shared that they were concerned about Destiny because she never wants to interact with other children, rarely smiles or laughs, and has mood fluctuations with little or no pattern or trigger. Reactions include irritability, sadness, and tearfulness.
History:
Destiny arrived at the Mases’ when she was two years old and was nonverbal at the time. Destiny also showed cognitive delays in her early intervention screening. Darlene and Tony noticed Destiny’s lack of interest in playing with other children when Destiny arrived and she did not want to interact with the other children in the home. The irritability and mood fluctuations began over a year ago. Darlene and Tony were hopeful that once Destiny started preschool that she would start interacting with others, however this is not the case. | null | Destiny's treatment goals should include? | Look for other placement alternatives | Reviewing past negative experiences | Keeping Destiny from other children for now | Building new attachment relationships between the child and caregiver | (A): Look for other placement alternatives
(B): Reviewing past negative experiences
(C): Keeping Destiny from other children for now
(D): Building new attachment relationships between the child and caregiver | Building new attachment relationships between the child and caregiver | D | Destiny and Ms Maze would benefit from some work on their relationship and this may help destiny develop a sense of emotional security. Reviewing past negative experiences may increase the guilt and tension that is already present. Although Ms Maze appears frustrated, it is not necessary yet to look at other placement alternatives. Destiny is acting the way that she is because of her early attachment experiences. Finally, it would be beneficial to provide Destiny with positive social experiences so she can see the value of supportive relationships and practice social skills. Keeping Destiny from other children would not allow her to have these experiences. Therefore, the correct answer is (C) | treatment planning |
658 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | You work with the client and their parents to help the parents understand how the client conceptualizes their gender identity. You use the client’s self-identified, gender-affirming pronouns and praise the client for taking a brave first step. The client’s mother is fearful and anxious, particularly when thinking about the client’s safety. The client’s father expresses an overall lack of understanding and thinks it could be a phase. You recognize the father’s efforts to understand and help the client explain the distressing emotions associated with coming to terms with their gender identity, including an increase in severity since the onset of adolescence. The father states that he is unsure if he can accept the client’s transgender identity but says that he is committed to the counseling process. You provide ongoing assessment for any associated mental disorders that may further complicate the client’s coming out process | You provide ongoing assessment for any associated mental disorders that may further complicate the client’s coming out process. According to the DSM-5-TR, gender dysphoria is comorbid with all of the following EXCEPT: | Anxiety disorders | Depressive disorders | Attention-deficit/hyperactivity disorder (ADHD) | Autism spectrum disorder | (A): Anxiety disorders
(B): Depressive disorders
(C): Attention-deficit/hyperactivity disorder (ADHD)
(D): Autism spectrum disorder | Attention-deficit/hyperactivity disorder (ADHD) | C | According to the DSM-5-TR, gender dysphoria is associated with all of the answer choices except ADHD. Per the DSM-5-TR, adolescents that are referred with gender dysphoria most commonly present with anxiety and depressive disorders, while children that are referred with gender dysphoria commonly present with autism spectrum disorder. For most males, adolescence starts between the ages of 10 and 14. Identifying comorbid diagnoses or symptoms can help counselors select appropriate interventions and address any additional barriers affecting the client. For example, considerations for gender-diverse individuals on the autism spectrum may require a tailored approach for effectively handling social transitions and interpersonal relationships. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
659 | Client Age: 4 Sex: Female Gender: Female Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not applicable Counseling Setting: Private Practice Clinic Type of Counseling: Family Therapy Presenting Problem: Foster Care; Disengaged Child; Behavioral Problems Diagnosis: Provisional Diagnosis of Reactive Attachment Disorder (F94.1) | Mental Status Exam: The client is disengaged, and when the foster parents prompt her to answer questions, she ignores them and continues playing. The client appears oriented to person, place, time, and situation because she answered questions about these topics. The client appeared more responsive to your questions than her foster par | You are a private practice counselor specializing in working with children with developmental disorders. The 4-year-old female client is referred to you by her PCP and arrives with her foster parents, who join her in the first session. The client has been with her foster parents for the last 13 months after being removed from the care of her biological parents due to their incarceration for drug trafficking and attempted armed robbery. The foster parents are worried because the client exhibits minimal positive mood, irritability without an obvious trigger, and behaviors that appear to be clearly connected to attachment with caregivers. She experienced emotional and physical neglect from the birth parents and changes in primary caregivers. The foster parents also report that the client does not seek comfort when something happens that upsets her. The client did not engage very much in the intake session and was instead playing with the toys provided by the counselor. During the session, the client becomes upset with her foster parents when they prompt her to answer some questions. She hits the foster father, runs out to the lobby, and sits down with the toys. You leave the office and meet her in the lobby. | ents. Family History: The client entered foster care 1 year ago when her parents were arrested on charges of drug trafficking and armed robbery. The client has been with the same foster parents for the past year. The client experienced emotional and physical neglect by her birth parents and was separated from her 5-year-old brother and 2-year-old sister when she entered foster care. He appears to have had trouble with attachment to the foster parents per the foster parents’ report | All of the following are appropriate treatment objectives for reactive attachment disorder EXCEPT: | Assist the foster parents with demonstrating expectations, feedback, and structure to demonstrate that they are in control. | Assist the foster parents with reframing the client’s problem behaviors as opportunities to support and love their foster child. | Instruct the client on cognitive reframing on anxiety about being with the foster parents. | Develop trust and comfort with the client. | (A): Assist the foster parents with demonstrating expectations, feedback, and structure to demonstrate that they are in control.
(B): Assist the foster parents with reframing the client’s problem behaviors as opportunities to support and love their foster child.
(C): Instruct the client on cognitive reframing on anxiety about being with the foster parents.
(D): Develop trust and comfort with the client. | Instruct the client on cognitive reframing on anxiety about being with the foster parents. | C | The client is too young to have a cognitive focus in therapy because she will have trouble processing thoughts and feelings about her situation. Developing trust and comfort with the client is important because she is unengaged in therapy and may need help feeling comfortable with adults in order to engage in therapy. The foster parents would benefit from learning to reframe problem behaviors as opportunities to build their relationship with their foster child. They would also benefit from providing expectations, feedback, and structure on a consistent basis, which shows the client that her caregivers are in control and have her best interests in mind, which might help her manage strong emotions. Therefore, the correct answer is (D) | counseling skills and interventions |
660 | Client Age: 60 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Unemployment; Anxiety; Depressed Mood Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client appears to have a depressed mood as evidenced by his affect, slow speech pattern, and body posture. The client is dressed appropriately for the season and is in clean clothing. The client is oriented to person, place, time, and situa | You are a private practice therapist working in an outpatient clinic. Your 60-year-old male client comes into the intake session, sits down, and sighs deeply. You verbally acknowledge that the client looks as though he is carrying a big mental weight, and he nods. The client begins to talk about how he was let go from his job at an assembly plant a month prior due to budget cuts. The client says that he worked there for about 30 years and that he was most recently a plant manager for the past 10 years. The client states that the plant shut down because the automotive company moved their manufacturing to another country. The client expresses anxiety surrounding what he is going to do for work next. The client states that he worries that he does not have much to offer other employers due to the extent of time he spent at his last job and also that his age will make him unemployable. The client says that he has been isolating himself, feels down more often than not, and often worries about making ends meet. The client states that his wife is currently receiving cancer treatment and, because of this, they have significant, regular medical bills. | tion. Family History: The client has been married for 25 years. He has three children, a 23-year-old son, a 21-year-old son, and an 18-year-old daughter. The client reports a strong relationship with his wife and children and states that they regularly spend quality time together | Which of the following would be considered a positive attending trait for a therapist? | Using hand gestures to appear engaged | Saying “yes,” “right,” and “uh huh” or using head nods to show that you are listening | Speaking in a slow, soft, gentle tone | Turning your body 45 degrees away from the client to minimize a seemingly aggressive body posture | (A): Using hand gestures to appear engaged
(B): Saying “yes,” “right,” and “uh huh” or using head nods to show that you are listening
(C): Speaking in a slow, soft, gentle tone
(D): Turning your body 45 degrees away from the client to minimize a seemingly aggressive body posture | Speaking in a slow, soft, gentle tone | C | Speaking in a slow, soft, gentle tone can encourage thought and engagement from the client and is a positive attending trait that can be used by the therapist (Sommers-Flanagan & Sommers-Flanagan, 2015, p 64). Using hand gestures and frequently stating “yes” or “uh huh” along with head nods can interrupt the client by making them think that you have more to say, or it may make them avoid eye contact in order to avoid the distraction of seeing frequent head nodding (Sommers-Flanagan & Sommers-Flanagan, p 65). Turning your body slightly away from the client may come across as being disengaged, whereas facing the client with an open body posture is more engaging. Therefore, the correct answer is (A) | core counseling attributes |
661 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Private practice Type of Counseling: Individual | Taylor presents as well groomed, has good eye contact, and movements are within normal limits. Taylor appears anxious with tense affect and is occasionally tearful. Taylor has no history of suicidal thoughts or behaviors, no reported trauma history and has never been in counseling. | Diagnosis: Adjustment disorder with anxiety (F43.22)
You are a counseling intern working in a private practice with your supervisor and several other interns. Taylor is a 29-year-old college student who was referred to you by her university’s resource center for mental health counseling. Taylor went to them requesting someone to talk to about her family stress. Taylor’s 18-year-old brother has autism and is preparing to go to college in another state, and Taylor is feeling anxious about the transition since he will be leaving home for the first time and their family will not be around to help him. Taylor has been manifesting her anxiety in ways that are causing her difficulty in school and in her relationship, such as trouble concentrating, completing assignments, and lashing out with aggressive reactions towards her parents or her boyfriend whenever they bring up the topic of her brother’s college. She has even yelled at her brother once out of frustration. Taylor is hoping to find ways to cope with her stress and manage her emotions over her family’s decisions. | Family History:
Taylor lives at home with her parents and her brother, and commutes to University for her Bachelor studies. She stayed at home since graduating high school to help her parents with her brother with autism. Her parents had separated on and off for several years because of an affair her mother had, so the house has had tension and instability making Taylor feel responsible to keep her brother on a stable routine. Taylor comments that her brother’s challenges have always “taken up all her time” and that she used to complain about them, but now that he is going to be on his own, she is very upset she will not be able to be there for him. She complains her parents are “flaking out” on her and feels left out of their decision making but does not know what to do about it. | You have empathy for Taylor and her situation, but you do not want to cross boundary lines by providing services for her brother with autism while in session with Taylor. You assess it best that her brother is given a referral for a different provider. This approach encompasses which counseling trait? | knowledge of group therapeutic factors | sensitivity to disability issues | awareness of self and impact on clients | non-judgmental stance | (A): knowledge of group therapeutic factors
(B): sensitivity to disability issues
(C): awareness of self and impact on clients
(D): non-judgmental stance | awareness of self and impact on clients | C | Having an awareness of your boundaries and whether your prior knowledge will affect your delivery of services for your client is paramount in being an effective counselor. Regardless of your sensitivity to Taylor's brother's autism, it is important that if you feel you are crossing a boundary in supporting her brother at the same time as Taylor that you respect this decision by following through and then offer alternative options for support. It is always expected that you have a non-judgmental stance and unconditional positive regard towards your clients. Knowledge of group therapy factors is important but not relevant here. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
662 | Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3) | Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg | You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers. | The client appears to be more comfortable with you as he greets you at the door and starts talking with you about his favorite TV show as you walk back to the office. The client talks about how his parents give different consequences to him than his younger sister and that they also give her more attention than they give him. You empathize with the client about this because it must be frustrating being treated differently. You assist the client with processing further, and he identifies feeling like he is “bad.” But because he gets attention, he continues to push back against their authority. During this session, the client curses at his parents and they punish him by removing access to video games for the next week | Which one of the following CBT terms most accurately defines the counselor’s encouragement of the client to try to ask his parents for something in a calm, polite manner to see if there is a different outcome than when he yells and curses? | Behavioral experiment | Guided discovery | Exposure therapy | Role play | (A): Behavioral experiment
(B): Guided discovery
(C): Exposure therapy
(D): Role play | Behavioral experiment | A | A behavioral experiment is when the client engages in a behavior to see if it results in their expected outcomes or to see if the outcome changes. This can be helpful in treating anxiety because the client can see that their predicted outcomes are often worse than the actual outcomes. Role playing involves acting out different situations in order to prepare for a future situation. Exposure therapy is used for anxiety and phobias and involves exposing a client to their fears/phobias. This is done in small increments in order to increase the client’s comfort and confidence in those situations and to show the client that the threat is not as extreme as anticipated. Guided discovery involves exploring different perspectives and providing evidence for and against certain beliefs. Therefore, the correct answer is (A) | counseling skills and interventions |
663 | Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0) | Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through | You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational. | The client comes to the session, sits down, and is quiet. The parents report that prior to the session he was playing an online game and became so upset that he threw his video game console. The parents express frustration that they do not know what to do when this happens. You provide psychoeducation to the client regarding coping skills to manage frustration. You find out that the parents respond by removing access to video games, and this usually results in yelling back and forth with the parents and the client. The parents do typically encourage the client to listen to music because this appears to be very effective in calming him down. The client expresses frustration with the people that he was playing with by saying that they “cheated and are lying about it.” You support the client with cognitive reframing | All of the following are helpful therapeutic modalities for behavioral problems related to autism spectrum disorders, EXCEPT: | Applied behavior analysis | Behavior therapy | Speech-language therapy | Cognitive behavioral therapy (CBT) | (A): Applied behavior analysis
(B): Behavior therapy
(C): Speech-language therapy
(D): Cognitive behavioral therapy (CBT) | Speech-language therapy | C | Speech-language therapy is an essential component of treatment for autism spectrum disorder that focuses on enhancing the ability to communicate with others, but it is not focused on the behavior problems related to autism spectrum disorder. Cognitive behavioral therapy (CBT), behavior therapy, and applied behavior analysis are all beneficial in treating behavior issues related to autism. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
664 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement. | You are a counselor in a private practice setting. During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships. He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements. | Family History:
The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it. | In addition to assessment, what other interventions would be most helpful for you in understanding the client's presenting issues? | Family session including the client and his husband | Family session including the client, his husband, and their children | Family session including the client and his brother | Family session including the client and his parents | (A): Family session including the client and his husband
(B): Family session including the client, his husband, and their children
(C): Family session including the client and his brother
(D): Family session including the client and his parents | Family session including the client and his husband | A | Clients present for counseling with a limited perspective of the problem as they understand and interpret it. Inviting the client's spouse into the session provides an understanding of how the interpersonal relationship between the two is navigated and allows the counselor to have an additional dimension in understanding of the client's concerns. While inviting the client's children to session would provide an understanding of how he interacts with them, this is not the presenting concern. While the client has a good relationship with his brother, the relationship with his spouse is the one experiencing problems at this time. The client is emotionally and physically cut off from his parents so inviting them into session at this time during therapy would be inappropriate. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
665 | Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions. | You are a counselor in a private practice setting. Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly. Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.” | Family History:
The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting. | Psychodynamic therapy is helpful because clients with OCPD tend to focus more on which of the following? | Delegating rather than self-completion | Emotions rather than the end results of a task | Task completion rather than perfection | Logic rather than emotions | (A): Delegating rather than self-completion
(B): Emotions rather than the end results of a task
(C): Task completion rather than perfection
(D): Logic rather than emotions | Logic rather than emotions | D | Clients with OCPD focus more on logic and orderliness, rather than emotions. Emotions and expressions of emotionality interfere with the rigidity of the OCPD client. The need to control one's self and environment requires the OCPD client to use logic rather than emotions as the latter leave the OCPD individual vulnerable to rejection if he or she does not respond with perfection. This can lead to individuals with OCPD appearing socially awkward, cold, and unfeeling about others' needs. Psychodynamic therapy helps the OCPD client learn to identify, explore, and express their emotions through increasing self-awareness and insight. Individuals with OCPD do not focus on emotions over the end results of a task and the individual will be more focused on perfection than task completion (Criterion 2). Additionally, individuals with OCPD rarely delegate tasks to others, instead completing themselves, unless the other agrees to do a task exactly how the individual with OCPD has instructed (Criterion 6). Therefore, the correct answer is (B) | counseling skills and interventions |
666 | Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20) | Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam | You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together. | ily and Work History: The client worked briefly as an office manager but became a stay-at-home mom once she had kids. As a devout Catholic, she reports feeling heartbroken and ashamed that her husband is filing for divorce. The couple frequently entertained guests at their home, which abruptly stopped after their separation. Her oldest daughter is not speaking to her and is “taking her father’s side,” which has caused her great sadness and resentment. Her middle child, who lives locally, is married with children but does not allow the client to visit her grandchildren unsupervised. She believes her children’s father has spread lies about her alcohol use and feels he “drinks just as much” but appears to do so with impunity. The client’s mother was addicted to pain pills, and her father was diagnosed with bipolar disorder. The client witnessed interpersonal violence between her parents as a child and often felt unsafe growing up. History of Substance Use and Addictive Behavior: The client first started drinking at the age of 14. Her drinking increased significantly while in college and in her early 20’s. The client was able to stop drinking through her three pregnancies but began to drink daily when her children became school-aged. She acknowledges that drinking during the day first started while waiting in the school’s carpool line and increased when her husband returned home from work. She has received three DUIs and had the third offense expunged. After the third DUI, she was court-ordered to attend Alcoholics Anonymous. She stated she resented having to “get a piece of paper signed” and being asked to attend 90 meetings in 90 days. The client denies substance use beyond experimenting with marijuana in college. She concedes that alcohol has been problematic in the past but feels she can successfully control her intake. You are nearing the end of your initial intake session | You are nearing the end of your initial intake session. Which of the following actions would best help improve treatment compliance for this client? | Summarize the client’s presenting problem, barriers to treatment, and associated risks of prolonged alcohol use. | Facilitate the negotiation of agreed-upon treatment goals. | Teach basic relaxation and mindfulness techniques to help improve insomnia. | Provide the client with information for online and in-person 12-step recovery meetings. | (A): Summarize the client’s presenting problem, barriers to treatment, and associated risks of prolonged alcohol use.
(B): Facilitate the negotiation of agreed-upon treatment goals.
(C): Teach basic relaxation and mindfulness techniques to help improve insomnia.
(D): Provide the client with information for online and in-person 12-step recovery meetings. | Facilitate the negotiation of agreed-upon treatment goals. | B | The therapeutic alliance is associated with instilling hope, optimism, and motivation—all of which are related to improved treatment compliance. One way to establish a therapeutic alliance is to negotiate agreed-upon treatment goals for therapy. This client-counselor collaborative relationship is also strengthened by having confidence in the methods used to attain these identified goals. Due to the client’s previous dissatisfaction with Alcoholics Anonymous, providing the client with 12-step recovery information would not be beneficial at this time. The therapist’s communication skills, including summarization, can positively affect the therapeutic alliance; however, summarizing the client’s problems, barriers, and risks is problem-oriented rather than solution-oriented. Providing problem-focused feedback can prevent the client from joining with the therapist. Relaxation and mindfulness are evidence-based approaches for improving insomnia. Teaching these skills does not ensure successful mastery of the client’s alcohol use, and the client may want to prioritize other issues. Therefore, the correct answer is (D) | treatment planning |
667 | Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry. | First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week. Fourth session The client has been seeing you every Tuesday and likes to schedule his weekly appointments a month in advance. Last week, you asked him to bring in a list of the triggers for his anger and the strategies he has tried in the past to manage it. You explained that this would help you create an individualized treatment plan with specific goals and objectives to work on throughout therapy. Furthermore, you suggested coming up with potential coping strategies to employ if/when he finds himself in a situation in which he feels the need to withdraw or avoid. You also stressed the importance of identifying and addressing any underlying issues contributing to this behavior. Today, you spend the session exploring his anger and constant road rage, and you help him identify his feelings. He recognizes that the rage comes from a sense of being disrespected and feeling taken advantage of. As you continue that discussion, the client has a revelation. He recognizes that he also feels insignificant, unappreciated, and taken advantage of by his adult children. He wonders aloud if they like him. You focus on providing a positive therapeutic empathic response to meet his need to connect in relationships. | null | What would be the most objective way to assess your counseling effectiveness with the client? | Discuss openly with the client whether he believes he is making progress | Review your therapy notes to compare the client's current issues with the intake | Measure the client's progress in therapy using an outcomes assessment | Ask the client to self-monitor using therapist-generated criteria | (A): Discuss openly with the client whether he believes he is making progress
(B): Review your therapy notes to compare the client's current issues with the intake
(C): Measure the client's progress in therapy using an outcomes assessment
(D): Ask the client to self-monitor using therapist-generated criteria | Measure the client's progress in therapy using an outcomes assessment | C | An example would be using the Interpersonal Relationship Inventory (IPRI) to evaluate how his relationships with his children might have improved overall. Find assessments which measure what you are looking for. Determine which counseling outcomes assessment you are most comfortable using. As effective as a tool may be, if you do not utilize it regularly to solicit client feedback, you will not realize the benefits. Therefore, the correct answer is (A) | treatment planning |
668 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | bile. Family History: The client has two younger brothers who are 6 and 7 years old. The client often engages in physical fights and arguments with his younger siblings and often will break or steal their toys. The client takes advantage of his 6-year-old sibling by conning him out of items and activities by convincing him that a certain trade or decision is better for him, when it is usually better for the client. The client’s parents report that these behaviors occur at school and that the client does not have any friends as far as they are aware. The client’s parents state that the client is adopted and that he was in foster care from when he was 2 until he was 4 years old. The client’s parents state that his basic needs were neglected because his birth mother was heavily using drugs. It will be important to build rapport with this client to provide effective counseling | It will be important to build rapport with this client to provide effective counseling. Which of the following would most effectively promote therapeutic rapport with this client? | The client is young; therefore, the parents will likely be the ones using interventions so it is more important to have rapport with the parents. | Spend a few sessions trying to play with the client. | Rapport will be built over time, so continue to be consistent and creative with your sessions. | Empathize with the client’s view of why he engages in these behaviors. | (A): The client is young; therefore, the parents will likely be the ones using interventions so it is more important to have rapport with the parents.
(B): Spend a few sessions trying to play with the client.
(C): Rapport will be built over time, so continue to be consistent and creative with your sessions.
(D): Empathize with the client’s view of why he engages in these behaviors. | Empathize with the client’s view of why he engages in these behaviors. | D | The client is likely often in trouble with his parents, and teachers and other adults likely side with his parents when he is in trouble. It would be beneficial to your counseling relationship to show the client that you understand why he engages in these behaviors and why he might be frustrated or angry or why he may feel misunderstood. Rapport will be built over time, but coming alongside your client by helping him feel like you are on his side and that you want him to be happy and enjoy himself will be much more beneficial and more proactive. Providing enjoyable activities or playing with your client might increase rapport; however, the client is old enough to engage in cognitive therapeutic work, which might be more beneficial. Although it is important to support the parents, you are the client’s therapist and you need to promote his interests and help him engage in them in a more appropriate manner. Therefore, the correct answer is (B) | counseling skills and interventions |
669 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client is engaging in restrictive eating daily. The client engages in bingeing when her husband is away for business trips and engages in exercise as compensatory behavior. Diagnosis: Anorexia nervosa, binge eating/purging type, moderate (F50.02) | Mental Status Exam: The client is oriented to person, place, time, and situation. She reports no hallucinations or paranoia. The client was engaged in the session, but she had trouble accepting that her weight and self-talk were problem | You are a licensed counselor working in your own private practice, and you specialize in eating disorders. The client comes to counseling after her primary care physician (PCP) provided a referral to counseling due to restrictive eating that has led to a low body mass index of 16.5. The client says that she has lost about 30 pounds over the past 6 months and that she still feels that she is overweight. The client says that she usually consumes about 500 calories each day and that she fears that if she eats more, she will gain weight. The client’s mother, who was overweight, passed away at age 46 due to an aneurysm, which has contributed to the client’s perception that her mother’s death was weight related. The client expresses that she also has a fear that if she gains weight, then her husband will not love her. She describes experiencing anxiety resulting from the belief that she is currently overweight and is therefore already at risk of both her husband not loving her and of dying. The client says that she generally restricts eating when her husband is home, but when he is on business trips she binges and then forces herself to throw up. | You meet with the client in your office 1 week after the intake session. The client reports that her husband was out of town for half of the past week and she engaged in bingeing and purging. You review the client’s food log with her and can see the difference between when her husband is home and when he is gone based on her documentation. The log included the client’s thoughts following bingeing, purging, and restricting, and you and the client work on creating new scripts for the thoughts that have led to unhealthy eating and compensatory behaviors in the past | Which one of the following drugs has been proven beneficial in treating anorexia nervosa? | Amitriptyline (a tricyclic antidepressant) | Olanzapine (an antipsychotic) | Fluoxetine (a selective serotonin reuptake inhibitor [SSRI]) | Diazepam (a benzodiazepine) | (A): Amitriptyline (a tricyclic antidepressant)
(B): Olanzapine (an antipsychotic)
(C): Fluoxetine (a selective serotonin reuptake inhibitor [SSRI])
(D): Diazepam (a benzodiazepine) | Olanzapine (an antipsychotic) | B | The only medication with evidence-based proof of effectiveness in treating anorexia nervosa is olanzapine, a second-generation antipsychotic that has proven to be effective in the case of severe illness associated with drastic weight loss in anorexia. Olanzapine has shown the ability to aid in weight gain in this scenario. Antidepressants such as SSRIs and tricyclic antidepressants have not shown evidence of improving the negative behaviors associated with anorexia or in improving negative thoughts and distorted self-image, although antidepressants, specifically fluoxetine, have been recommended and are proven effective in the treatment of bulimia nervosa. Benzodiazepines slow down the information traveling between the brain and body and are not an effective treatment of anorexia nervosa. Therefore, the correct answer is (D) | treatment planning |
670 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | use. Family History: The client has a close relationship with his parents and his older sister. The client has close friends. The client inquires about his counseling records when you are explaining informed consent | The client inquires about his counseling records when you are explaining informed consent. Which of the following statements is the most accurate with regard to the client’s records? | The counselor must make reasonable precautions to ensure the privacy of client records in the event of termination, incapacity, or death. | Client records must be kept for at least 5 years before being appropriately destroyed. | You can share session notes with your counseling resident for educational purposes because they are practicing under your license. | When the client requests his records, you must provide full access to the records and support their interpretation as needed. | (A): The counselor must make reasonable precautions to ensure the privacy of client records in the event of termination, incapacity, or death.
(B): Client records must be kept for at least 5 years before being appropriately destroyed.
(C): You can share session notes with your counseling resident for educational purposes because they are practicing under your license.
(D): When the client requests his records, you must provide full access to the records and support their interpretation as needed. | The counselor must make reasonable precautions to ensure the privacy of client records in the event of termination, incapacity, or death. | A | The most factual statement regarding client records is with regard to making reasonable precautions in case you are suddenly unable to continue services. Even if a counseling resident is practicing under your license, you still need to obtain written consent for release of information to your resident. When a client requests records, if there is a risk of foreseeable harm, you can restrict access to some or all of the client’s chart. You should keep the client’s records within the bounds of the state’s laws within which you practice, which is typically a certain number of years, but the length of time varies based on the state in which you are licensed. Some clients have situations that might suggest that you keep records longer such as those having court involvement or abuse/neglect allegations. Therefore, the correct answer is (D) | professional practice and ethics |
671 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | You and the client meet 4 days after the initial intake session due to truancy because she has missed several days of school. For about half of the session, the client seems to be withdrawn. She asks you what you are required to report, and you remind her of the limits of confidentiality. The client says that she understands, and then says she is going to talk about what happened anyway. She says that her volleyball coach asked to meet with her after practice about 7 months ago and when she entered his office, he asked to look at her right thigh following a fall during practice. She continues to state that when she showed him, he started to touch her genital area from the outside of her pants. She states that she ran out of the room and went home. She explains that after this event she quit the team and told her parents that she did not want to play anymore, but recently she has started to experience distressing memories of the sexual abuse; she refuses to go to school because she would see the man daily; she has difficulty feeling happiness; and she is experiencing feelings of shame, insomnia, and difficulty concentrating. You praise the client for disclosing this information and empathize with her about how hard it must have been to share this experience | Which of the following would be the most appropriate next step due to the information provided during this session? | Invite the parents into the session to discuss the information provided, and report the information to the appropriate local government agency. | Invite the parents into the session to discuss the information provided. | You are a mandated reporter and will report this to the appropriate local government agency. | Invite the parents back into the session to discuss the information that was provided, and receive a release of PHI to report this to the school. | (A): Invite the parents into the session to discuss the information provided, and report the information to the appropriate local government agency.
(B): Invite the parents into the session to discuss the information provided.
(C): You are a mandated reporter and will report this to the appropriate local government agency.
(D): Invite the parents back into the session to discuss the information that was provided, and receive a release of PHI to report this to the school. | Invite the parents into the session to discuss the information provided, and report the information to the appropriate local government agency. | A | As a therapist, you are a mandated reporter and must report all incidents of abuse or neglect to the local government agency that investigates those reports, such as the local child protective services office. It is also important to make the parents aware of what happened, and, although the client does not need to consent to this, you already know that she is okay with this because she said so earlier in the session. The client does not need to consent, but it is beneficial to the counseling relationship that she has consented to you breaking confidentiality. A release of PHI to talk with the school may be helpful but is not required to ensure the client’s safety. It may be helpful to create a safety plan with the family to ensure that the client is not in a position to be sexually abused by this individual again at school. Reporting the incident to the local government agency and collaborating with the parents are the minimal steps needed at this point in therapy. Therefore, the correct answer is (D) | professional practice and ethics |
672 | Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice | The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations. | First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me." You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy." You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week. | The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially. | Your agency's intake procedure involves a mental status exam as well as a self-reported history. How does this information, along with your immediate observations of the client's mental state inform the next steps in treatment? | Treatment should focus on providing immediate stabilization. | Treatment should focus on developing positive affirmations to improve self-esteem. | The client should be encouraged to increase social activities and build relationships. | The client should be admitted to an in-patient facility for evaluation of possible self-harm. | (A): Treatment should focus on providing immediate stabilization.
(B): Treatment should focus on developing positive affirmations to improve self-esteem.
(C): The client should be encouraged to increase social activities and build relationships.
(D): The client should be admitted to an in-patient facility for evaluation of possible self-harm. | Treatment should focus on providing immediate stabilization. | A | The client is in a vulnerable mental state, and it is important to take steps to ensure his safety. Treatment should focus on providing immediate stabilization. Therefore, the correct answer is (B) | treatment planning |
673 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training. | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | How would you use positive reinforcement after the client tells you how he handled the incident at school? | "You did a great job taking a deep breath and walking away when you felt angry. Let's choose a fun activity or game to play at the end of our session today." | "You did a great job handling your anger at school! You should be proud of yourself for making that choice." | "It sounds like you worked hard this week to stay in control, even when it was difficult." | "You managed the situation at school really well. Let's see if you can respond in the same way the next time you feel angry, okay?" | (A): "You did a great job taking a deep breath and walking away when you felt angry. Let's choose a fun activity or game to play at the end of our session today."
(B): "You did a great job handling your anger at school! You should be proud of yourself for making that choice."
(C): "It sounds like you worked hard this week to stay in control, even when it was difficult."
(D): "You managed the situation at school really well. Let's see if you can respond in the same way the next time you feel angry, okay?" | "You did a great job taking a deep breath and walking away when you felt angry. Let's choose a fun activity or game to play at the end of our session today." | A | Positive reinforcement is a powerful tool for motivating someone to continue desirable behaviors. In this case, you can use positive reinforcement by offering the client a fun activity or game as a reward for using appropriate strategies for managing his emotions. By doing so, you are providing him with an incentive to keep up the good work. Therefore, the correct answer is (C) | counseling skills and interventions |
674 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. Second session The client had an appointment to meet with you two weeks ago, but she called to reschedule twice, citing a busy work schedule. The client shows up 10 minutes late for her second counseling session today, looking slightly disheveled. She starts off by telling you that "this morning has been a mess." She overslept and missed two appointments with clients. She contacted her secretary to reschedule the appointments, but she is still feeling stressed and overwhelmed. She tells you she was up late last night talking to her ex-boyfriend. You ask what motivated her to talk with her ex-boyfriend and she tells you, "It felt like the only way I could make sense of what had happened between us." She is not forthcoming with any additional details about their conversation. You then ask if anything else has been on her mind lately. She reports that her mother told her that she should be focusing more on finding someone new to date instead of worrying about getting back together with her ex. The client becomes distant and quiet during the session. She makes minimal eye contact and her responses are brief, often giving a one-word response to your questions. You can tell that something has shifted in her since last week's session as she presented to the intake as more talkative and open. You decide to address her change in behavior directly, saying "I notice that you seem more closed off today compared to the last session we had. Is there something specific that is causing you to feel this way?" The client responds, "I don't know, I'm just so tired of it all." When you ask her to elaborate, she closes her eyes and takes a deep breath before responding. She says that she feels emotionally drained. She is overwhelmed with the weight of all that has been happening and feels like she is a "total failure" for allowing things with her ex-boyfriend to come this far. She describes feelings of guilt for "treating him like dirt" the entire time they were together and sad that "I messed things up so badly." She also shares that she is feeling ashamed about being charged with a DUI. She says, "I'm an attorney, not a criminal. People like me don't get DUIs, yet here I am. What's wrong with me?" The client expresses both a desire and a fear of change. She often talks about wanting to make changes in her life, but is also uncertain about how to go about it, feeling overwhelmed by the idea of taking action. Her tone reveals a sense of hopelessness as she talks about where her life is headed. You empathize with her, acknowledging the difficulty of changing deeply-rooted patterns. You provide her with psychoeducation about the nature of addictions and the biological and environmental factors that can contribute to substance abuse. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | By the end of the session, you have identified several issues that the client will need to work on in therapy. Which of the following has the most potential to affect the client's engagement and long-term therapeutic progress? | Feeling overwhelmed and stressed | Strained Family relationships | Lack of a support network | Time constraints | (A): Feeling overwhelmed and stressed
(B): Strained Family relationships
(C): Lack of a support network
(D): Time constraints | Time constraints | D | The client appears to have difficulty making it to her scheduled appointments and showing up on time, which could significantly impact her engagement with therapy and her long-term progress. Time constraints can be a major barrier for many clients in seeking help, and the fact that this client is already struggling to make time for therapeutic sessions indicates that she may need additional support or encouragement to prioritize her own wellbeing. Therefore, the correct answer is (D) | treatment planning |
675 | Name: Ruth and Dale Clinical Issues: Parenting/co-parenting conflicts Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse or Intimate Partner Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Agency | Appearance: The client is casually dressed and adequately groomed. She appears healthy, and her age is consistent with her stated age. Behavior: The client's behavior is tense and purposeful. She is cooperative with adequate rapport. Speech: Speech volume is normal, and speech flow is normal and spontaneous. Mood: The client's mood is dysphoric and anxious. Thought Process: Thought process is logical. Thoughts are negative. Affect: The client's affect is broad and appropriate to the discussion. Cognition: The estimated level of intelligence is within average range with abstract thinking. Concentration is intact. The client shows no problems with memory impairment. Insight and Judgment: Insight is fair. Impulse control and judgment appear to be below average. | First session You are a therapist working at a marriage counseling agency. Ruth is a 41-year-old female who comes to your office with her husband. The couple has been married for seven years and have two children, ages five and one. The husband also has a 16-year-old daughter from a previous marriage who lives in the home. The client is a stay-at-home mom, and her husband works at a correctional institution. Their five-year-old has been removed from three separate daycare facilities because of her defiant behavior. In addition, the 16-year-old was recently arrested for shoplifting. At the end of the session, the client turns to her husband and says, "I'm the one who has to stay home with the kids all day. You just don't get it. You don't know what it's like having no time for yourself and no quiet place to relax. You think all this stuff with the kids is a normal phase and everyone will grow out of it. Well, I don't think it's normal, and I'm tired of it! I've been talking to my ex-husband lately because he listens to me, and I feel better after I talk to him." Ruth demonstrates elevated stress and anxiety levels, as evidenced by her verbalization of feeling overwhelmed by the demands of caring for their children and lack of personal time. She also expresses feelings of frustration with her husband, who she perceives as not understanding her struggles. Her husband's absence during the day and the children's challenging behaviors have likely contributed to the client's feelings of isolation and burnout. Ruth's decision to reach out to her ex-husband for emotional support may indicate that she is not receiving adequate support from her current partner. Third session In accordance with Ruth's decision at the last session, she ceased communication with her ex-husband. After affirming this, she turns to her husband and says, "He called twice last week, but I didn't answer. At least someone wants to talk with me!" Dale gives her an exasperated look, folds his arms over his chest, and shakes his head in disgust, at which Ruth says, "See? That's all I ever get! Nothing!" and begins to cry. Dale seems angry but remains quiet. Dale sighs and rubs his temples. "This is why I don't talk about it," he says. "You always make it about you. Do you think I don't want to talk to you? Do you think I don't care?" Ruth sniffs and wipes her eyes. "Of course not, but it feels like you don't want to talk to me. Like you don't care. You never talk to me, and then you get quiet when I try to talk to you." Dale rolls his eyes. "That's because you don't listen when I try to talk to you. You just jump to your own conclusions and then get mad at me when I don't do what you think I should do. I'm tired of it. I'm tired of trying to talk to you, but you never listen." Ruth bristles, tears streaming down her face. "Well, what am I supposed to do? You never tell me what you want me to do, so how am I supposed to know?" Dale throws his hands and walks away in frustration. "I don't know, Ruth. I really don't know." Tenth session The couple enters in better spirits than previously. They have been speaking with each other in the lobby while waiting. They enter laughing. Ruth reports that the communication techniques you shared seem to have helped. She no longer feels the need to leave her husband. They report that the 16-year-old daughter arrived home from her time at the crisis center somewhat subdued by the experience, although still showing challenging behaviors. They also say that the five-year-old still exhibits defiant behaviors at home and school. The couple had worked hard to repair their communication and marriage, which is paying off. The husband and wife have found a new understanding and mutual respect. They have developed newfound patience and empathy for one another, helping to create a more harmonious environment at home. The couple had also applied the communication techniques they had learned to their interactions with their children. As a result, Ruth and her husband are now workings together to find a way to better understand and respond to their children's needs. They have set up a school conference to determine how to handle their children's behavior. | Ruth's parents died in a boating accident while she was in college. She has two brothers and one sister, but they are not close, partially due to the strain of losing their parents. Her husband's first wife left him soon after their daughter was born. She does not discuss her place in the family's dysfunction but talks about other family members who need help. Ruth has been unable to heal her relationship with her sister and feels guilty about it. She also expresses concern for her husband's well-being after his first wife's divorce, which she was partly responsible for. Additionally, Ruth struggles with depression and anxiety due to trauma related to the death of her parents. Personal/Social Relationships: Ruth feels that her husband minimizes their children's problems and is to blame for their lack of improvement. Ruth feels her marriage is "on the rocks.'" Her husband knows his wife is unhappy but does not know what to do. Finally, you learn that Ruth recently reconnected with her ex-husband and is seriously considering having an affair. Previous Counseling: The client has been working on her low self-esteem through therapy but says she is not getting any better. Her husband says, "I know Ruth is unhappy. That much is obvious. She's stressed out all the time, and she's stopped talking to me. She gets in the car, is gone for hours, and isn't home when I arrive after work. I'm worried I will lose her, but I don't know what to do." | Which is not considered ethical concerning records and documentation? | The client has the right to access his/her own record. | The therapist does not need to store records for more than seven years after termination. | The therapist must obtain permission from a client to record a session. | The therapist will take precautions to maintain confidentiality of the client records if the therapist leaves or is terminated from a practice. | (A): The client has the right to access his/her own record.
(B): The therapist does not need to store records for more than seven years after termination.
(C): The therapist must obtain permission from a client to record a session.
(D): The therapist will take precautions to maintain confidentiality of the client records if the therapist leaves or is terminated from a practice. | The therapist does not need to store records for more than seven years after termination. | B | This is not an ethical statement. You must take care to store client records after termination for a period of time that is determined by federal or state laws, not just seven. In addition to taking care of client confidentiality, careful deliberation should be taken before destroying any documents which could be needed in court (ie, child abuse, violence, and sexual harassment). Therefore, the correct answer is (C) | professional practice and ethics |
676 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | bile. Family History: The client has two younger brothers who are 6 and 7 years old. The client often engages in physical fights and arguments with his younger siblings and often will break or steal their toys. The client takes advantage of his 6-year-old sibling by conning him out of items and activities by convincing him that a certain trade or decision is better for him, when it is usually better for the client. The client’s parents report that these behaviors occur at school and that the client does not have any friends as far as they are aware. The client’s parents state that the client is adopted and that he was in foster care from when he was 2 until he was 4 years old. The client’s parents state that his basic needs were neglected because his birth mother was heavily using drugs | Which of the following is an appropriate assessment tool to confirm the client’s diagnosis of conduct disorder? | Diagnostic Interview for Children and Adolescents | Child Behavior Checklist | Conners Continuous Performance Test | Delinquent Activities Scale | (A): Diagnostic Interview for Children and Adolescents
(B): Child Behavior Checklist
(C): Conners Continuous Performance Test
(D): Delinquent Activities Scale | Diagnostic Interview for Children and Adolescents | A | The Diagnostic Interview for Children and Adolescents tests for many different DSM-5-TR disorders including conduct disorder. This can be helpful in ensuring that the diagnosis is accurate and that it is not a different disorder. There is also a version that can be given to the parents to validate the assessment results given to their child. The Conners Continuous Performance Test can provide supporting information to validate the conduct disorder diagnosis, but it is geared more toward impulsivity in the test-taking environment. The Child Behavior Checklist assesses for many behaviors and can support the diagnosis, but it would not specifically lead to a diagnosis of conduct disorder. The Delinquent Activities Scale does diagnose conduct disorder specifically but only for incarcerated adolescents. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
677 | Initial Intake: Age: 4 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Clinic Type of Counseling: Individual | Destiny was engaging with the counselor throughout the interview although her affect was flat. She played by herself while the counselor spoke to Darlene and Tony. She did not look up at her parents or engage with them during the entire session. | Destiny is a 4-year-old who was referred for therapy by her preschool teacher. Destiny arrived at the intake session with her adoptive parents, Darlene and Tony Mase. Darlene and Tony shared that they were concerned about Destiny because she never wants to interact with other children, rarely smiles or laughs, and has mood fluctuations with little or no pattern or trigger. Reactions include irritability, sadness, and tearfulness.
History:
Destiny arrived at the Mases’ when she was two years old and was nonverbal at the time. Destiny also showed cognitive delays in her early intervention screening. Darlene and Tony noticed Destiny’s lack of interest in playing with other children when Destiny arrived and she did not want to interact with the other children in the home. The irritability and mood fluctuations began over a year ago. Darlene and Tony were hopeful that once Destiny started preschool that she would start interacting with others, however this is not the case. | null | A non-projective assessment that measures emotional symptoms, functioning, social behavior and hyperactivity is? | Stanford Binet | Thematic Apperception Test (TAT) | The Strengths and Difficulties Questionnaire (SDQ) | House-Tree-Person (HTP) | (A): Stanford Binet
(B): Thematic Apperception Test (TAT)
(C): The Strengths and Difficulties Questionnaire (SDQ)
(D): House-Tree-Person (HTP) | The Strengths and Difficulties Questionnaire (SDQ) | C | The Strengths and Difficulties Questionnaire is used to measure emotional symptoms, functioning, social behavior, and hyperactivity. The Stanford Binet is an intelligence test with an age range of 2 years through adulthood. The house-tree-person test (HTP) is a projective test intended to measure different aspects of personality. Test takers are asked to draw a house, a tree, and a person. The interpretation of these drawings is used to create a picture of the person's cognitive, emotional, and social functioning. The Thematic Apperception Test (TAT) is a projective test comprised of ambiguous pictures of scenes. The subject is asked to describe what is happening in the scene. Similar to the House-Tree-Person, the interpretation of the drawings is used to determine current problems and functioning. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
678 | Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20) | Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam | You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together. | ily and Work History: The client worked briefly as an office manager but became a stay-at-home mom once she had kids. As a devout Catholic, she reports feeling heartbroken and ashamed that her husband is filing for divorce. The couple frequently entertained guests at their home, which abruptly stopped after their separation. Her oldest daughter is not speaking to her and is “taking her father’s side,” which has caused her great sadness and resentment. Her middle child, who lives locally, is married with children but does not allow the client to visit her grandchildren unsupervised. She believes her children’s father has spread lies about her alcohol use and feels he “drinks just as much” but appears to do so with impunity. The client’s mother was addicted to pain pills, and her father was diagnosed with bipolar disorder. The client witnessed interpersonal violence between her parents as a child and often felt unsafe growing up. History of Substance Use and Addictive Behavior: The client first started drinking at the age of 14. Her drinking increased significantly while in college and in her early 20’s. The client was able to stop drinking through her three pregnancies but began to drink daily when her children became school-aged. She acknowledges that drinking during the day first started while waiting in the school’s carpool line and increased when her husband returned home from work. She has received three DUIs and had the third offense expunged. After the third DUI, she was court-ordered to attend Alcoholics Anonymous. She stated she resented having to “get a piece of paper signed” and being asked to attend 90 meetings in 90 days. The client denies substance use beyond experimenting with marijuana in college. She concedes that alcohol has been problematic in the past but feels she can successfully control her intake. You ask your client the following: “On a 1-10 scale, with 10 being the highest, How confident are you that you can stop drinking altogether?” The client states, “I would say a 6 | You ask your client the following: “On a 1-10 scale, with 10 being the highest, How confident are you that you can stop drinking altogether?” The client states, “I would say a 6.” Using motivational Interviewing, which response would best elicit change talk? | “Tell me more about how you decided you are a 6.” | “Why are you not a 10?” | “What would your life look like if you were at a 7?” | “Why are you a 6 and not a 0?” | (A): “Tell me more about how you decided you are a 6.”
(B): “Why are you not a 10?”
(C): “What would your life look like if you were at a 7?”
(D): “Why are you a 6 and not a 0?” | “Why are you a 6 and not a 0?” | D | Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET) are evidence-based treatment practices that employ a person-centered, strengths-based approach to reduce ambivalence and evoke lasting behavioral change. The confidence ruler is an MI strategy that uses scaling questions to determine the client’s desire to change. By asking, “Why are you a 6 and not a 0?” the client may then respond by providing reasons why she feels confident in her ability to stop drinking, such as abstinence attained during her three pregnancies. This technique helps initiate a conversation about the client’s perceived ability to change. Asking, “Why are you not a 10?” shifts the conversation to one that is problem-based rather than strengths-based. “Tell me more about how you decided to be a 6” may elicit some degree of change talk, but it is not as precise as the response produced when using the MI confidence ruler technique. Lastly, asking the client what her life would look like if she had greater confidence in her ability to stop drinking does not help reduce ambivalence in the same way answer B does. Therefore, the correct answer is (B) | counseling skills and interventions |
679 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam | You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions. | You learn that the client withheld information during the intake interview because of a negative experience with psychiatric treatment. Two years previously, the client presented at the emergency room with symptoms of depression and suicidal ideation. The emergency department clinician recommended hospitalization, and the client complied. During his hospital stay, he was placed on an antipsychotic medication for paranoia and was diagnosed with schizoaffective disorder. Although the client admits to suicidal ideation, he denies ever experiencing paranoia. He reports having side effects from the medication and immediately discontinued it after discharge. The client states that he has been very depressed since the breakup with his girlfriend and was willing to give counseling another try before his depression “hit rock bottom | Which of the following would you select to evaluate the client’s cognitive distortions by testing them against sound logic and reason? | Socratic questioning | Counterconditioning | Assuming responsibility | Forceful disputing | (A): Socratic questioning
(B): Counterconditioning
(C): Assuming responsibility
(D): Forceful disputing | Socratic questioning | A | Cognitive therapists use Socratic questioning to help challenge cognitive distortions and evaluate their automatic thoughts by testing them against sound logic and reasoning. For example, the counselor may ask, “What is the evidence for or against this thought?” The client then learns to recognize automatic thoughts and their associated cognitive distortions independently, which is all part of a process known as cognitive restructuring. Counterconditioning is an unrelated term used by behavioral therapists to refer to an experimental procedure in which a subject is trained to respond to a stimulus incompatible with a previously learned response to the same stimulus. Forceful disputing is a rational-emotive behavioral therapy technique used to challenge irrational thoughts and beliefs. Assuming responsibility is a gestalt therapy technique. Gestalt therapists using this technique ask clients to add the phrase, “and I take responsibility for it,” to statements to help promote personal responsibility for their thoughts, actions, and feelings. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
680 | Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20) | Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam | You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together. | During the previous session, the client committed to controlled drinking and agreed on a limit of two drinks per night. She admits to having limited success with this goal and concedes to over-indulging when feeling “stressed out.” You learn she ran into a woman from her church who she discovered was a recovering alcoholic. She agreed to meet the woman at an AA meeting, and the client was surprised she could relate to other alcoholics. The client’s affect brightened as she reported that she has had seven days of continuous sobriety. She continues to have a strained relationship with her now ex-husband. Her youngest child is home on spring break, which has helped improve her mood and kept her accountable for staying sober. She is able to use relaxation and mindfulness techniques for insomnia, which have been effective at times at improving her sleep pattern. You continue your discussion with the client, stating, “You’ve mentioned your ex-husband knows how to push your buttons, and you feel he has caused you to increase your alcohol consumption in the past | You continue your discussion with the client, stating, “You’ve mentioned your ex-husband knows how to push your buttons, and you feel he has caused you to increase your alcohol consumption in the past. Can you tell me more about what your mood is like right after those interactions?” What is the value in asking this question within the context of cognitive-behavioral therapy? | To help create a subjective units of disturbance (SUD) scale | To convey genuineness and unconditional positive regard | To uncover unconscious forces that drive behavior | To help guide the development of a functional analysis | (A): To help create a subjective units of disturbance (SUD) scale
(B): To convey genuineness and unconditional positive regard
(C): To uncover unconscious forces that drive behavior
(D): To help guide the development of a functional analysis | To help guide the development of a functional analysis | D | The value in posing this question is to help guide the development of a functional analysis. A functional analysis increases the effectiveness of cognitive-behavioral therapy (CBT) by using the ABC model to examine and understand the sequence of thought patterns and behaviors. The ABC model examines antecedents (A), or what comes before the behavior, the actual behavior (B), and the consequence of that behavior (C). Establishing what the client’s mood is like right after interacting with her ex-husband helps connect the behavior, antecedents, and consequences. Person-centered therapy, rather than CBT, is characterized by genuineness and unconditional positive regard. Psychoanalytic theorists focus on uncovering unconscious forces that drive behavior. Counterconditioning, a form of classical conditioning, uses a subjective unit of disturbance scale (SUDs) to assess levels of distress so events with lower levels of arousal can counteract these events. Biofeedback is an example of counterconditioning that incorporates the use of SUDs. Therefore, the correct answer is (A) | counseling skills and interventions |
681 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. Fourth session Last week you met with the client's parents to discuss behavioral parent management training, educating them on how this approach can be used to decrease disruptive behavior and encourage positive behaviors. You taught them how to identify and reinforce desired behaviors and asked them to start keeping a log to record the client's behaviors during the day, what actions they took in response to his behaviors, and how he responded. Additionally, you suggested introducing rewards for meeting goals and discussed the importance of consistency. They followed up with you prior to today's appointment, stating that they believe the parent management training has been beneficial so far, as they have seen a slight decrease in disruptive behaviors and an increase in compliance. The client arrives for his fourth individual session with you. When you ask him how he has been feeling this week, he states that he does not want to go to math class because they "move too fast," and he cannot keep up. The client says he does not feel it is fair that "the teacher yells at me every day even when I'm trying my best." He says, "She's mean, and I won't go back to her class ever again!" He is displaying signs of anger and frustration. His arms and legs are tense, he is tapping his feet, and his facial expression is scrunched up in a frown. His breathing is shallow and rapid. You attempt to calm him down by guiding him in a breathing exercise that you first introduced during a previous session that involves taking slow, deep breaths. You repeat this exercise a few times with the client until he is feeling calmer. In order to further explore the client's feelings about math class, you ask that he draw a picture of the classroom and how it makes him feel. He draws an angry teacher standing in front of a chalkboard with a lot of numbers written on it in random order. The client says that this is how his math class feels to him: overwhelming and confusing. You explain to the client that you understand how overwhelmed and confused he feels, and that it can be really hard to focus on a task when it feels too hard. You also assess the client's perceptions of the teacher, noting his feelings of mistrust and apprehension. Additionally, you assess the client's ability to self-regulate in the classroom and his overall attitude towards class participation. You talk to him about some strategies to help him feel more comfortable in class, and you also reassure him that you are going to talk to his math teacher. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | What short-term goal would you work on first with this client? | Discuss communication strategies with the teacher | Learning simple relaxation techniques | Teach the parents how to assist the child with math homework | Reviewing math homework before class | (A): Discuss communication strategies with the teacher
(B): Learning simple relaxation techniques
(C): Teach the parents how to assist the child with math homework
(D): Reviewing math homework before class | Learning simple relaxation techniques | B | The client is clearly anxious and frustrated. Teaching him some relaxation techniques which he can use to calm down is appropriate as a short-term goal. Therefore, the correct answer is (A) | counseling skills and interventions |
682 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | ter. F amily History: The client’s paternal grandmother received legal guardianship when the client was in 1st grade due to parental neglect. The client’s mother and father have had ongoing issues with substance abuse. The client’s father is currently incarcerated for drug-related offenses. The PGM reports that the client’s mother continues to “run the streets” and shows up periodically asking for money. The PGM states that the client’s mother abused drugs while pregnant and that the client was born prematurely. In addition, the client’s father had similar school difficulties and dropped out of high school in the 10th grade. History of Condition: The client’s disruptive behavior began in early childhood. When the client was four years old, her tantrums were so severe that she disrupted two daycare placements and was not allowed to return. In kindergarten, the client was given a stimulant by her primary care provider to assist with symptoms of ADHD. The PGM says she is no longer on the medication and believes the client chooses to misbehave, explaining, “she is strong-willed, just like her father.” The client’s school records show she has an individualized education plan (IEP) and receives limited services for developmental delays in reading and written expression | Given the client’s clinical presentation, how would you structure the first individual session with the client? | Identify maladaptive cognitions. | Establish treatment plan goals. | Engage her in a therapeutic art activity. | Process grief and loss issues. | (A): Identify maladaptive cognitions.
(B): Establish treatment plan goals.
(C): Engage her in a therapeutic art activity.
(D): Process grief and loss issues. | Engage her in a therapeutic art activity. | C | Given the client’s clinical presentation, the best approach for your first session is to engage her in a therapeutic art activity. During the initial intake, the client proudly shared that her artwork came in 1st place. Focusing on the client’s strengths rather than the client’s clinical pathology helps establish a therapeutic alliance. The client has little to no contact with her parents, exhibits ODD behaviors at home and school, and is academically below grade level. Thus, the client’s social, emotional, and academic needs likely contribute to strained relationships with authority and have a higher probability of eliciting negative feedback. Identifying maladaptive cognitions is incorrect due to the client’s cognitive functioning. Establishing treatment plan goals is best accomplished after collecting relevant information from the client’s teacher and grandmother. Processing grief and loss issues, as it pertains to separation from her parents, is important but will likely be more effective after establishing the therapeutic alliance. Therefore, the correct answer is (D) | counseling skills and interventions |
683 | Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual | Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings. | Diagnosis: Acute Stress Reaction (F43.0), Provisional
You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established. | Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father. | You discuss here-and-now functioning. What data would indicate Acute Stress Disorder? | avoidance of her phone's photo album | recurrent distressing dreams and dissociative amnesia | changes in appetite | crying when her siblings ask where mom is | (A): avoidance of her phone's photo album
(B): recurrent distressing dreams and dissociative amnesia
(C): changes in appetite
(D): crying when her siblings ask where mom is | recurrent distressing dreams and dissociative amnesia | B | The presence of recurrent distressing dreams and the inability to remember an important aspect of a traumatic event are both symptoms that indicate a stress reaction is advancing to disorder. While avoidance is also a disorder symptom, it can also be considered a normal and healthy reaction to a trauma of this severity. Changes in appetite are concerning and should be monitored but are to be expected with extreme stress, and an emotional reaction to a sibling's unfulfilled need to see their mother is clinically appropriate. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
684 | Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported. | First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom. Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school. During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience. As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself. Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions. Third session As the session progresses with Logan, you notice that he seems more withdrawn and less willing to participate in your planned activities. You ask him how he has been feeling since your last session and if he has progressed in handling the bullying situation at school. Logan hesitates to answer your questions, looking down and avoiding eye contact. He eventually shares that the bullying has intensified and he feels overwhelmed and helpless. He tells you about the boys in his gym class calling him names and making fun of him. He says they continue to bully him, says he "won't ever go to school again," and "hopes those boys die." As an REBT practitioner, you emphasize the importance of determining some of his core issues contributing to his distress. You ask him to share some of the thoughts he has had about the bullying and the boys in his gym class. Logan admits that he believes he is "worthless" and "deserves the bullying" because he is not "cool" enough. You help him recognize that his self-worth is not dependent on the opinions of his bullies and that he does not deserve to be mistreated. You also address Logan's intense emotions and help him understand the relationship between his thoughts, feelings, and actions. You encourage Logan to reflect on the possible consequences of wishing harm upon his bullies and discuss alternative, healthier ways of coping with his feelings. You introduce Logan to relaxation techniques, such as deep breathing exercises and progressive muscle relaxation, which he can use to manage his emotional distress. In this session, you also explore Logan's social support network to identify potential allies to help him deal with the bullying. You ask him about friends, family members, or other school staff who he trusts and feels comfortable talking to about his experiences. Logan mentions a few friends who he thinks might be willing to help. You discuss ways he can approach these individuals and ask for their support, emphasizing the importance of open communication and honesty. When he gets ready to leave, you notice a cigarette fall out of his backpack. You ask him about the cigarette, and he admits that one of the boys in his gym class gave it to him. He says the boy said if Logan smoked it, he would be "cool" and finally accepted by them. You explain to Logan that smoking is not an excellent way to fit in and can harm his health. Instead, you encourage him to find other ways to express himself, such as participating in activities he enjoys or joining clubs at school. Following today's session, you check in with Logan's mother. You also advise her on how she can support her son by having conversations with him about the importance of making good choices and helping him find healthy ways to cope with his feelings. | The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family. | Which of the following REBT techniques would have you employed to help Logan recognize that his self-worth is not dependent on the opinions of his bullies, and that he does not deserve to be mistreated? | Role-playing | Rational emotive imagery | Rebutting irrational beliefs | Systematic desensitization | (A): Role-playing
(B): Rational emotive imagery
(C): Rebutting irrational beliefs
(D): Systematic desensitization | Rebutting irrational beliefs | C | Disputing irrational beliefs is an effective REBT technique that involves challenging and replacing unhelpful, self-defeating beliefs with healthier, more rational ones. By disputing the irrational belief that his self-worth depends on others' opinions, Logan can learn to recognize that his value is inherent and not tied to external judgments, allowing him to develop a healthier self-image and reduce the impact of bullying. Therefore, the correct answer is (D) | counseling skills and interventions |
685 | Name: Ella Clinical Issues: Seeking help after experiencing a trauma Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.0 Acute Stress Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is a 35-year-old white female with a slender build. She is wearing jeans and a t-shirt and appears to be clean and well groomed. Her posture is slumped, her facial expression is flat, her eyes are downcast, and she has been displaying signs of crying. She speaks softly in a monotone voice. The client appears depressed and anxious, with tearfulness and trembling. She seems overwhelmed by her current situation and is unable to control her emotions. She reports difficulty concentrating on day-to-day activities. Her thoughts are logical and organized with tangential moments. She reports feeling as if she is living in a dream-like state since the trauma occurred. She experiences frequent nightmares about people she loves being killed. She is able to recall her personal history accurately. She is able to understand and follow your instructions and questions. She recognizes that she needs help. She denies suicidal ideation or intent. | First session You are a mental health counselor working in a private practice setting while under supervision. The client is a 35-year-old white female who presents for therapy following a trauma. When you ask the client why she made an appointment to see you, she begins to cry and shake uncontrollably. She tells you that her friend was shot two weeks ago and the client saw it happen. Her friend is in the intensive care unit at the hospital. She cannot consciously recall the actual shooting. Since the assault, she cannot concentrate and feels anxious all the time. She does not want to talk to her friends, and she has been withdrawing from her family. The client tearfully tells you that "life has no meaning." She is seeking your help to find some relief. You validate the client's emotions and begin processing her subjective experience. You help her to understand that witnessing such a traumatic event can lead to the physical and emotional symptoms that she is experiencing. She appears receptive to what you are saying and nods her head. You emphasize that she has taken a courageous step by seeking professional help. As you continue with the initial session, you focus on providing an empathetic space where she can explore her feelings without fear of being judged. You provide her with information about resources she can access for further help. You also discuss the principles of cognitive-behavioral therapy as a method to begin to process her traumatic experience. Before the session ends, you present relaxation exercises that she can practice at home in order to reduce distress and tell her that learning healthy coping skills will be an important part of her recovery. Following the session with your client, your supervisor tells you that she has worked extensively with the client’s parents in the past and offers to give you their files so that you can understand more of the client's family history. Second session After meeting with the client for the initial session, you thought it would be beneficial to meet with her again in a few days. She scheduled an appointment to meet with you via telehealth three days after her initial visit. You begin today's session by discussing potential avenues of treatment. The client reports not sleeping well because of vivid nightmares. She excessively worries about losing her parents but does not want to concern them. Since the assault, she has withdrawn from her family. She reports becoming angry when they suggest that she go for a walk outside to "get some fresh air". She now believes they do not care that she feels unsafe. The client denies suicidal ideation but sometimes feels she would be better off not waking up in the morning. During the first 10 minutes of the session, the client's two pet dogs continually draw her attention away from the session. You notice the distraction and acknowledge it. You ask the client if she would like to take a break and play with her dogs for a few minutes. The client agrees and takes a few minutes to interact with her animals. When she is finished, she escorts the dogs out into the hallway and returns to her room, closing the door behind her. You sit with the client and share a compassionate space together, allowing her to share her vulnerable feelings. You notice that, as you talk, her two pet dogs are still being disruptive, barking in the hallway, and distracting her from the conversation. You bring her attention back to the session by reiterating your understanding of how she has been feeling since the assault. You then explain that these feelings may be compounded by the disruption caused by her pets during their sessions. You offer suggestions on ways to create a better environment for therapy such as having another family member manage the pets while they work together, or setting up a comfortable area in another room where she can work with you away from distractions. The client is appreciative of your suggestion and agrees to put some of these ideas into practice for their next session. From here, you move onto discussing potential treatment options for her recovery. You explain the benefits of cognitive behavioral therapy and how it can help her in managing her feelings more effectively. Additionally, you share relaxation techniques with the client to help reduce her physical symptoms of distress. Finally, you work collaboratively with your client on developing coping skills and increasing self-care practices in an effort to improve her overall well-being. You end the session feeling that progress has been made, both in terms of providing an understanding environment and suggesting ways to further address the trauma she experienced. | The client's family has a long history of living in the Bronx, New York, as her great-great-grandparents immigrated from Italy. She currently lives with her parents in a house that has been in her family for generations. Her entire life she has always felt safe and secure living in her Italian neighborhood. The client has one older brother who is married and works as a paramedic. She is close to her parents and describes them as supportive, hardworking, and loving. Her father was diagnosed with cancer several years ago and she has tried to be there for him in every way possible. Stressors & Trauma: The client witnessed her friend being shot during a robbery. Since then, she cannot stop thinking about the event. As a result, she has insomnia and frequent nightmares about people she loves being killed. She is unable to stop shaking and crying when discussing the nightmares. In addition, the event has left the client feeling angry, confused, ashamed, depressed, and highly anxious in her day-to-day activities. | Given the client's passive thoughts of death but denial of suicidal ideation, how might you proceed to help the client with the ongoing effects of her trauma? | Work with the client on reframing and coping skills | Contact necessary authorities to request a wellness check on the client after the session | Immediately create a safety plan | Shift the focus away from the trauma to the client’s presenting symptoms | (A): Work with the client on reframing and coping skills
(B): Contact necessary authorities to request a wellness check on the client after the session
(C): Immediately create a safety plan
(D): Shift the focus away from the trauma to the client’s presenting symptoms | Work with the client on reframing and coping skills | A | The client feels overwhelmed by the challenge that the recent trauma has made to her current worldview. Consolidation of the meaning of the trauma and reworking her schemas about the world are essential for this client. Additional recommendations include giving the client a list of contacts she can utilize if she feels in crisis in the future and continually monitoring the client’s passive thoughts of death during sessions. Therefore, the correct answer is (A) | counseling skills and interventions |
686 | Initial Intake: Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: VA Type of Counseling: Individual | Carl came to the intake session alone and angrily stated, “I really don’t know why they are making me come to therapy - it doesn’t help anyway.” Carl appeared edgy throughout the interview and responded to questions with minimal effort.
| Carl is a 38-year-old Army Veteran who is attending counseling at the local VA. Carl was referred after he was arrested for a DUI last week.
History:
Carl has been on four deployments to the Middle East, he returned from the most recent tour 11 months ago, after he was injured during a military strike. Some of his team members were injured as well.
Since his return, Carl and his civilian wife, Lori, have discussed separation because of their frequent arguing and Carl’s drinking. Carl began drinking when he was deployed and since then has used it as a coping mechanism to combat the frequent flashbacks and nightmares that he gets. Carl and Lori mostly argue about money since Carl has not been able to sustain employment as a construction worker because of his drinking problems. Carl has been arrested several times for assault and disorderly conduct. Carl recently assaulted his last counselor after he had made a comment about Carl not being able to sustain work.
The counselor thanked Carl for his service and reviewed with him that he was referred as a part of his probation. He must attend individual therapy and an anger management group for veterans. The counselor then described to Carl the purpose of the meeting and what would be reviewed and discussed during their time together. This included the intake paperwork, including informed consent and several assessments. | null | Carl's statement of realizing he has a problem is which of the Prochaska and DiClemente's stages of change? | Precontemplation | Action | Contemplation | Preparation | (A): Precontemplation
(B): Action
(C): Contemplation
(D): Preparation | Contemplation | C | Carl's statement indicates that he is in the contemplation stage in which he is aware that he has a problem but has not yet committed to change. Precontemplation is a stage when a person does not see that he/she has an issue and has no intention of changing his/her behavior. In the preparation stage, the individual is determined to make changes and believes that he/she is capable of change. In the action stage, the person is taking the established steps to make change. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
687 | Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3) | Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg | You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers. | iene. Family History: The client’s parents are married, and he has a younger sister who is 6 years old. The client often deliberately annoys or angers his younger sister and has difficulty following directions from his parents. The client states, “My parents suck! They only care about my younger sister | The client states, “My parents suck! They only care about my younger sister.” Which one of the following statements would best be defined as a reflection of feeling by the counselor? | “I can see how you might be frustrated or sad if you feel like they don’t care about you.” | “That sounds like it could feel very lonely or that maybe you feel overlooked.” | “It sounds like you don’t like your parents very much because you feel like they only care about your sister.” | “You seem bothered by their attention at times, but do you wish you had a different kind of attention?” | (A): “I can see how you might be frustrated or sad if you feel like they don’t care about you.”
(B): “That sounds like it could feel very lonely or that maybe you feel overlooked.”
(C): “It sounds like you don’t like your parents very much because you feel like they only care about your sister.”
(D): “You seem bothered by their attention at times, but do you wish you had a different kind of attention?” | “That sounds like it could feel very lonely or that maybe you feel overlooked.” | B | Expressing that the client might feel lonely or overlooked is a reflection of feeling, which is a method of deducing and acknowledging the emotions behind what the client has stated. Sometimes, this technique is beneficial because the client may not be aware of the roots of his feelings. Responding to the client’s statement with a question about how he might be bothered by attention or may want different attention would be the use of clarification. Relating to the client’s feelings by saying that you can understand how he might feel sad or frustrated is an expression of empathy. Identifying that you hear the client saying that he does not like his parents because they prefer his sister is an example of paraphrasing. Therefore, the correct answer is (B) | counseling skills and interventions |
688 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | In connection with the client speaking about her boyfriend leaving her, the client made the statement, "I can't live with the pain of our separation much longer, and I don't know how to cope with it". You recognize that the client is asking for help in dealing with her possibly overwhelming feelings concerning this emotional loss. Which tool would you select to evaluate the client further? | Keirsey Temperament Sorter (KTS) | Columbia Suicide Severity Rating Scale (C-SSRS) | Hamilton Anxiety Rating Scale (HAM-A) | Mini Mental State Examination (MMSE) | (A): Keirsey Temperament Sorter (KTS)
(B): Columbia Suicide Severity Rating Scale (C-SSRS)
(C): Hamilton Anxiety Rating Scale (HAM-A)
(D): Mini Mental State Examination (MMSE) | Columbia Suicide Severity Rating Scale (C-SSRS) | B | The Columbia Suicide Severity Rating Scale (C-SSRS) assesses the risk of suicide. There are three different versions of this assessment available to best suit the client's situation: the "lifetime/recent template," the "since the last visit" template, and the "screener" template. This instrument is appropriate to assist you in evaluating the client for suicidality. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
689 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e\. g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmental and Family History: The client’s mother and father are married, and the client has a sister who is 3 years old. The mother denies drug or alcohol use during pregnancy. She is a smoker but states that she cut down when she discovered she was pregnant with the client. The client was delivered at 34 weeks and weighed 5 pounds and 6 ounces. He stayed in the newborn intensive care unit for 10 days after delivery. The client was toilet trained at 24 months, walked at 12 months, and talked at 18 months. The client’s paternal grandmother has been treated for bipolar disorder. His maternal uncle has a history of substance abuse, which his mother cites as the reason why she is opposed to the client going on medication | ADHD is grouped under which DSM-5-TR classification? | Disruptive disorders | Neurodevelopmental disorders | Impulse-control disorders | Social engagement disorders | (A): Disruptive disorders
(B): Neurodevelopmental disorders
(C): Impulse-control disorders
(D): Social engagement disorders | Neurodevelopmental disorders | B | The DSM-5 classifies ADHD as a neurodevelopmental disorder. A separate DSM-5-TR classification is entitled Disruptive and Impulse-Control Disorders. This classification includes oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania. In addition, The DSM-5-TR classifies disinhibited social engagement disorder as a trauma- and stressor-related disorder. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
690 | Initial Intake: Age: 18 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Residence Type of Counseling: Individual | Nadia was initially resistant to the interview. She stated that she had been seeing counselors her whole life and none of them ever helped. Nadia had limited insight regarding her risk-taking behaviors. The counselor assessed that Nadia’s cognitive functioning appeared low. She stated that although she had contemplated suicide in the past, she currently had no intention or plan.
| Nadia is an 18-year-old in a community residence for children in foster care. She was referred for counseling because she has been running away from the group home, often for days at a time. Currently she is not getting along with her peers and gets into fights when they make comments about her activities, which is starting to affect everyone in the house.
History:
Nadia is one of 10 children by her birth parents. She has an extensive history of abuse and sexual exploitation by her parents until the age of 14 when she was removed from her parent’s care. Her and her siblings were sent to various foster homes as they could not all stay together. This is a subject that Nadia does not like to talk about since she was the oldest and had the responsibility to care for the younger ones. She feels as if she let them down. Nadia is frequently truant from school. For the past 4 years Nadia was in and out of foster homes due to her risk-taking behaviors and disrespect for others. She does have a good relationship with two staff members in the group home. | null | To assess cognitive and adaptive functioning in Nadia, the counselor may use all of the following, except? | SIB-R (scales of Independent Behavior- Revised) | CBCL | ABAS | Vineland | (A): SIB-R (scales of Independent Behavior- Revised)
(B): CBCL
(C): ABAS
(D): Vineland | CBCL | B | The Child Behavior Checklist (CBCL) is used to detect emotional or behavioral problems in children and adolescents. This would not be an appropriate test for Nadia as she is 18 years old. The Vineland Adaptive scales are used as a tool to diagnose intellectual and developmental disabilities and other disorders, ages birth-90. The scales of independent behavior revised is for individuals 3 months to 80 + years old and measures functional independence and adaptive functioning. The adaptive behavior assessment system is used to evaluate those with developmental delays, autism spectrum disorder, intellectual disability, etc. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
691 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | her. Family History: The client says that she has a good relationship with her parents. She says that they are encouraging and supportive of her. The client says that she has a younger brother who is 6 years old and an older brother who is 16 years old. The client states that she has a good group of friends and spends time with them regularly. Following the session, the client’s parents ask you for the details of your session with their daughter | Following the session, the client’s parents ask you for the details of your session with their daughter. What would be both the most ethical and clinically appropriate response? | You respect your client’s right to privacy and tell the parents you do not think it would be best for treatment to share information without the client’s consent. | You ask the client if you can talk with the parents, and she says “no,” but you are able to talk with them anyway because she is a minor. | First, you ask if you can talk with the client for permission and encourage the parents to provide their daughter with the space to speak freely during sessions. | The parents have a right to all information because the client is a minor, so you meet with them to discuss the details of the session. | (A): You respect your client’s right to privacy and tell the parents you do not think it would be best for treatment to share information without the client’s consent.
(B): You ask the client if you can talk with the parents, and she says “no,” but you are able to talk with them anyway because she is a minor.
(C): First, you ask if you can talk with the client for permission and encourage the parents to provide their daughter with the space to speak freely during sessions.
(D): The parents have a right to all information because the client is a minor, so you meet with them to discuss the details of the session. | First, you ask if you can talk with the client for permission and encourage the parents to provide their daughter with the space to speak freely during sessions. | C | You are balancing ethical and clinical concerns, and, in this situation, it is best for the client to be willing for you to talk with her parents and for the parents to accept a level of confidentiality for the client. If the client feels that she can talk with a level of confidentiality in the counseling sessions, then she is most likely to engage fully in treatment. The parents do have a right to all of the information, but this would not necessarily be clinically beneficial because the client may not trust you if you share all of the given information with her parents. If the client declines that you share information with the parents and the parents continue to request it, they do have a right to information, but it may not benefit treatment to do so. It is important to note that different states have different laws regarding the rights of minors in treatment. Therefore, the correct answer is (C) | professional practice and ethics |
692 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement. | You are a counselor in a private practice setting. During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships. He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements. | Family History:
The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it. | Which of the following would be the most appropriate next intervention to consider? | Couple's session to work on communication | Continue to work on client's substance abuse recovery | Individual counseling referral for spouse | Continue to work on client's attachment | (A): Couple's session to work on communication
(B): Continue to work on client's substance abuse recovery
(C): Individual counseling referral for spouse
(D): Continue to work on client's attachment | Couple's session to work on communication | A | The client has made progress in his alcohol recovery and in forming new attachments that encourage growth in his self-esteem. The presenting problem has always been the client's relationship with his spouse and this relationship, and while the roles are now reversed, it is still the presenting problem. It would be most helpful at this time to meet with the client and his husband to process the recent changes that the client has made and how these have impacted the couple. Counselors do not make referrals for people who are not clients so referring the client's spouse to individual therapy would be unethical. The counselor and client are able to continue work on his recovery and attachment while including the client's spouse as the relationship is tied to each of these. Therefore, the correct answer is (B) | treatment planning |
693 | Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual | Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. | Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. | Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. | You run into one of Jonny's teachers in the breakroom shortly after session and he says to you, "I hear you are meeting with Jonny, that's good. He really needs it." He sits down with you and asks, "Did he ask you to extend his deadlines? He's done that with all the counselors." How do you respond? | "I remember being stressed in college. These kids have so much to worry about!" | "Yes! He told me he has not done that before. I'll have a talk with him." | "No, he has not said anything like that. Why do you think he really needs counseling?" | "I cannot comment on things said in session, it is a violation of his trust." | (A): "I remember being stressed in college. These kids have so much to worry about!"
(B): "Yes! He told me he has not done that before. I'll have a talk with him."
(C): "No, he has not said anything like that. Why do you think he really needs counseling?"
(D): "I cannot comment on things said in session, it is a violation of his trust." | "I remember being stressed in college. These kids have so much to worry about!" | A | This response gently redirects the subject away from speaking about Jonny while also building rapport with his teacher. As a fellow staff member of the university, you are a team of professionals working together to help the students and may often need input from teachers to support your counseling efforts. Declining to comment out of confidentiality while a co-worker is showing interest and engagement in a fellow student can be viewed defensively, and you may lose your ally in providing Jonny well-rounded care. Lying about what Jonny has said or not said is also unhelpful. Asking a teacher for their input or observations of Jonny may be useful to your needs, but in this case, attempting to obtain input when you did not directly ask for it, is somewhat opportunistic. Also, a public break room during may not be the best time or place to discuss student therapy issues. Breaking Jonny's confidentiality as in answer a) is also unethical towards your therapeutic relationship with him. Therefore, the correct answer is (D) | counseling skills and interventions |
694 | Client Age: 25 Sex: Male Gender: Male Sexuality: Bisexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Telehealth Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty focusing on work due to a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) and thinks that if he cannot keep up with work, he is going to get fired. Diagnosis: Attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive presentation (F90.0) | Mental Status Exam: The client is oriented to person, place, time and situation. The client is engaged and participates fully in the intake session. The client does not appear anxious. The client has a flat af | You are a licensed counselor working in your own private practice and providing telehealth sessions to clients. The client states that he is having trouble keeping up with tasks at work. The client reports that he wakes up and does not want to go to work because he knows he will not get much done. The client is often late to work, and although he is typically the only one in the office, his employer comes to work every now and then, and he worries that he will get caught arriving late. He says that he procrastinates on tasks but, often near the end of the day, finds motivation to complete the tasks and stays late to do so. In addition to his trouble at work, the client says he thinks that he does not do much that makes him happy. He expresses the desire to write stories and play guitar more because these activities used to make him happy, but he has trouble finding motivation to engage in them at the present. | It has been 1 month since you last saw the client because he has canceled many sessions in a row without explanation. You process attendance with him and then ask him for updates regarding how symptoms have been over the last month. The client says that there were many reasons for cancellations, such as going to dinner with friends, being too tired, and forgetting about the session and making other plans. The client says that he got a new job and states that he is doing much better managing his ADHD symptoms in the new position. You and the client process what was difficult about his last position and then identify that these tasks are not present in the current position. A majority of this session was spent assessing the level of symptomatology experienced over the past month and the client reporting on events that occurred since the last session | Which of the following is the most therapeutic manner of determining the root of the client’s inconsistent attendance? | Asking the client, “What is most important to you for us to be working on in sessions?” | Asking the client, “Why have you been canceling sessions?” | Reviewing progress toward goals | Discussing scheduling to determine if the time or frequency is not working for the client | (A): Asking the client, “What is most important to you for us to be working on in sessions?”
(B): Asking the client, “Why have you been canceling sessions?”
(C): Reviewing progress toward goals
(D): Discussing scheduling to determine if the time or frequency is not working for the client | Asking the client, “What is most important to you for us to be working on in sessions?” | A | Identifying goals by determining what is important to the client would likely be the most helpful next step because the client has not been prioritizing his sessions. Refocusing on what is now most important to the client might increase motivation and participation. Over the course of therapy, needs change and therapy needs to be refocused to maintain motivation and to work toward meaningful goals. Asking “why” questions often puts the client in a position in which he feels the need to justify himself and can create defensiveness, which is not helpful in processing the client’s behavior. Reviewing previous treatment goals likely would not help very much because the client does not seem to be finding those goals meaningful anymore. Discussing scheduling likely would not be helpful because the client is actively scheduling other activities over the current scheduled sessions, which demonstrates that he has availability during this time but he is prioritizing other activities. Therefore, the correct answer is (C) | treatment planning |
695 | Initial Intake: Age: 68 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widow Counseling Setting: Community Agency Type of Counseling: Individual | The client presents appearing thin for height and older than her stated age. She is dressed in jeans and a shirt, no make-up and appropriate hygiene. Her mood is identified as euthymic and her affect is congruent. She is talkative and tells stories about herself and others, although she appears very distractible and changes subjects easily. She demonstrates appropriate insight, judgment, memory, and orientation using mental status exam questions. She reports never having considered suicide and never consider harming herself or anyone else. | You are a counselor in a community agency and your client presents voluntarily, though at the request of her family members. She tells you that her stepson and daughter-in-law told her they are concerned about her because she lives alone and they don’t believe that she can take care of herself at her home. She tells you that she is very happy living alone and is never lonely because she has over 20 indoor and outdoor cats that she feeds and they keep her company. During the intake, the client tells you that her husband of 33 years died five years ago from lung cancer. When asked why her family wanted her to come to counseling, your client says that she gets along well on her own; however, she believes that her stepson is looking for ways to take over her property. She tells you she owns a large section of land that includes two trailer homes, one of which is in better shape than the other so that is where she lives; ten or eleven vehicles, some that run and some that do not; and five large carports that hold the items that she and her husband used to sell at the daily flea market before it closed 15 years ago. She tells you that she sometimes finds uses for some of these items around her house but keeps all of them because they may “come in handy” at some point. She currently has no help on her property for mowing or upkeep, unless a neighbor or her son-in-law volunteers to help. | Family History:
The client reports that her parents divorced when she was a young teenager and she did not see her father again after that time. She reports he was an alcoholic as was her mother and they often argued. She relates that her mother did not work and she grew up with government assistance for food and shelter. She tells you that several years after the divorce, her mother’s mobile home was destroyed in a fire and the two of them lived in a friend’s trailer until they were able to buy another one to put on their property. She reports that she quit high school in 10th grade after having trouble reading for many years, married at age 16, had one daughter, and then divorced at 19 due to her husband’s continuing drug use. She tells you that her daughter has not been around for the “past few years” because she lives in another state and has some “mental problems, like bipolar something.” She tells you that she married again at age 20 and remained married to her husband until his death. She tells you her husband was a “good man” though he had many problems related to his military service in Vietnam and health problems due to smoking. She reports he had lung cancer and lived for 20 years although the doctors did not expect him to live so long. This was a second marriage for both of them and she tells you that her husband had one son. The client tells you she has not been close with her stepson because he has never helped them out and it has been worse since she stopped letting him keep his hunting dogs on her property. She tells you that he never took care of them and she had to feed them every day because he did not. The client tells you that she is close to her stepdaughter-in-law and that she trusts her much more than she does her stepson. The client tells you that she and her husband worked at the local flea market for many years selling things they had collected, but since the flea market closed 15 years ago, they lived on Social Security and the money her husband made doing “odd jobs” around town. | Considering the information provided, which question would be the most appropriate to ask when setting treatment goals for the client? | What might we work on in counseling to help you let go of the things you don't use anymore? | What might we work on in counseling to help your family feel less concerned about you? | What might we work on in counseling that would help you to take better care of yourself? | What might we work on in counseling that would help you to keep living well on your own? | (A): What might we work on in counseling to help you let go of the things you don't use anymore?
(B): What might we work on in counseling to help your family feel less concerned about you?
(C): What might we work on in counseling that would help you to take better care of yourself?
(D): What might we work on in counseling that would help you to keep living well on your own? | What might we work on in counseling that would help you to keep living well on your own? | D | When setting goals, it is critical to work with the client and what they want to accomplish. The client views herself as doing well on her own and being pushed by her family to live differently as a means of taking her property away from her. Setting goals that help the client improve what may or may not be a good living situation honors the client's values while creating space to work together. Asking the client about goals for better care suggests that the client is not taking good care of herself now and may create a sense of distrust in the client if she perceives the counselor as not believing her. Goals related to getting rid of possessions is likely to cause distrust in the client as this is not a goal that she has currently alluded to in the intake. Goals to help the family feel better are not appropriate goals for counseling as they are focused on pleasing someone other than the client. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
696 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | Which counselor attribute would not necessarily improve rapport between you and Mary? | congruence | non-judgmental stance | empathic responding | knowledge of widower issues | (A): congruence
(B): non-judgmental stance
(C): empathic responding
(D): knowledge of widower issues | knowledge of widower issues | D | All the above responses other than C are evidence-based skills that would help Mary feel understood and connected in session. Your knowledge as a counselor of widower issues or any clinical expertise will be useful in treatment, however, will not be likely support your therapeutic bond in and of itself. Therefore, the correct answer is (C) | core counseling attributes |
697 | Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong. | First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change. Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot. Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos. At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session. | The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy. | In what way does demonstrating unconditional positive regard to the client help her from a clinical standpoint? | This will help her to become more confident in herself and increase her self-esteem. | This will encourage her to be more compliant with treatment recommendations. | This will help her process difficult emotions more quickly and effectively. | This will help her to build trust in the therapeutic relationship and encourage open communication. | (A): This will help her to become more confident in herself and increase her self-esteem.
(B): This will encourage her to be more compliant with treatment recommendations.
(C): This will help her process difficult emotions more quickly and effectively.
(D): This will help her to build trust in the therapeutic relationship and encourage open communication. | This will help her to build trust in the therapeutic relationship and encourage open communication. | D | The focus of unconditional positive regard is about acceptance and understanding for the client as an individual. This helps to build trust in the therapeutic relationship so that open communication can occur. Open communication allows for more in-depth exploration of difficult emotions, which can then be addressed in a more meaningful and effective way. In this way, demonstrating unconditional positive regard to the client helps her from a clinical standpoint. Therefore, the correct answer is (B) | core counseling attributes |
698 | Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility | The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor. | First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. | The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father. | John Gottman refers to the four predictors that a marriage may be in trouble as the "Four Horseman of the Apocalypse." Which one of these is not one of the predictors? | Defensiveness | Dishonesty | Criticism | Contempt | (A): Defensiveness
(B): Dishonesty
(C): Criticism
(D): Contempt | Dishonesty | B | According to Gottman, this is not a predictor that a relationship is in trouble. The horsemen include Criticism, Defensiveness, Contempt, and Stonewalling. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
699 | Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual | Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving. | Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii. | Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed. | Which factor presents as the most likely underlying issue causing Malik's depression symptoms? | Cultural stress | Dad's criticism | Trauma | Feeling "overwhelmed" | (A): Cultural stress
(B): Dad's criticism
(C): Trauma
(D): Feeling "overwhelmed" | Trauma | C | Malik's mother reported her presentation of symptoms prior to leaving Hawaii, which follows the same timeline as Malik's report of a traumatic event occurring. Based on Malik's presentation of avoiding discussion of trauma, crying when she thinks of it and then deflecting, trauma is the best choice. Acculturation issues began after she moved, which likely exacerbated her symptoms but are not presenting as most plausible to be the primary cause. In this case, all other stressors reported are more likely contributing to her Anxiety disorder diagnosis. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
700 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. Second session The client had an appointment to meet with you two weeks ago, but she called to reschedule twice, citing a busy work schedule. The client shows up 10 minutes late for her second counseling session today, looking slightly disheveled. She starts off by telling you that "this morning has been a mess." She overslept and missed two appointments with clients. She contacted her secretary to reschedule the appointments, but she is still feeling stressed and overwhelmed. She tells you she was up late last night talking to her ex-boyfriend. You ask what motivated her to talk with her ex-boyfriend and she tells you, "It felt like the only way I could make sense of what had happened between us." She is not forthcoming with any additional details about their conversation. You then ask if anything else has been on her mind lately. She reports that her mother told her that she should be focusing more on finding someone new to date instead of worrying about getting back together with her ex. The client becomes distant and quiet during the session. She makes minimal eye contact and her responses are brief, often giving a one-word response to your questions. You can tell that something has shifted in her since last week's session as she presented to the intake as more talkative and open. You decide to address her change in behavior directly, saying "I notice that you seem more closed off today compared to the last session we had. Is there something specific that is causing you to feel this way?" The client responds, "I don't know, I'm just so tired of it all." When you ask her to elaborate, she closes her eyes and takes a deep breath before responding. She says that she feels emotionally drained. She is overwhelmed with the weight of all that has been happening and feels like she is a "total failure" for allowing things with her ex-boyfriend to come this far. She describes feelings of guilt for "treating him like dirt" the entire time they were together and sad that "I messed things up so badly." She also shares that she is feeling ashamed about being charged with a DUI. She says, "I'm an attorney, not a criminal. People like me don't get DUIs, yet here I am. What's wrong with me?" The client expresses both a desire and a fear of change. She often talks about wanting to make changes in her life, but is also uncertain about how to go about it, feeling overwhelmed by the idea of taking action. Her tone reveals a sense of hopelessness as she talks about where her life is headed. You empathize with her, acknowledging the difficulty of changing deeply-rooted patterns. You provide her with psychoeducation about the nature of addictions and the biological and environmental factors that can contribute to substance abuse. Fifth session It has been a month and a half since you first met with the client and she has rescheduled multiple therapy appointments, continually citing a busy work schedule. The last time you met with her, she told you that the judge sentenced her to six months probation, provided that she follow through with Alcoholic Anonymous meetings and counseling sessions. She was also required to do 60 hours of community service. Though she was relieved to have the sentencing behind her, she remarked that she still felt shame and humiliation at having gone down that path. During that counseling session, she communicated to you that she tried to go one day without drinking but couldn't do it. She described the idea of quitting drinking as "impossible" because "I have never been strong enough." You explored the client's motivations and concerns about changing her behavior. You explained to her that while it was normal to feel overwhelmed by the thought of making changes, there were strategies that she could utilize in order to build a support system and make progress towards sobriety. Based on the client's behavior, you do not believe that outpatient treatment is the best fit for the client at this time, and you plan to discuss alternate options with her today. She is scheduled for an afternoon session but does not show. When you attempt to call her, her phone goes directly to voicemail. You continue to wait in your office even though the client does not respond to your calls or appear for the session. You are concerned about her because although she has rescheduled appointments before, she has always done so in advance and has never been a "no show." You take the appropriate ethical actions to check on her. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | The client has missed several sessions and has shown a lack of commitment to therapy. What is the best way to introduce alternate options for the client's care? | "Based on your current needs, outpatient treatment may not be the best fit for you at this time, so I'd like to discuss some other options with you that might be more beneficial." | "You seem to have difficulty following through with your appointments, so let's talk about some different treatment options that may be more helpful to you." | "You have obviously been struggling with this, so let's explore some different options to see what could work better for you." | "I need to be honest with you. Your commitment to these sessions has been lukewarm. Individual counseling is not enough for your situation. I'd like to explore more intensive options." | (A): "Based on your current needs, outpatient treatment may not be the best fit for you at this time, so I'd like to discuss some other options with you that might be more beneficial."
(B): "You seem to have difficulty following through with your appointments, so let's talk about some different treatment options that may be more helpful to you."
(C): "You have obviously been struggling with this, so let's explore some different options to see what could work better for you."
(D): "I need to be honest with you. Your commitment to these sessions has been lukewarm. Individual counseling is not enough for your situation. I'd like to explore more intensive options." | "Based on your current needs, outpatient treatment may not be the best fit for you at this time, so I'd like to discuss some other options with you that might be more beneficial." | A | This response is sensitive and appropriate because it acknowledges the client's current needs, while still allowing room for discussion of alternative options. It also emphasizes that the client has a choice in her care plan, which can help build trust and mutual respect between the therapist and client. Finally, it avoids any language that could be seen as judgmental or critical of the client. Therefore, the correct answer is (A) | professional practice and ethics |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.